Free [PFP#970398992] - Virginia

Form 7

FORM 7. STATEMENT OF FINANCIAL AFFAIRS

UNITED STATES BANKRUPTCY COURT
EASTERN VIRGINIA ______________________________ DISTRICT OF ______________________________

In re: ______________________________________,
(Name) Debtor

Case No. ___________________________________
(if know n)

STATEMENT OF FINANCIAL AFFAIRS
This statement is to be completed by every debtor. Spouses filing a joint petition may file a single statement on which the information for both spouses is combined. If the case is filed under chapter 12 or chapter 13, a married debtor must furnish information for both spouses whether or not a joint petition is filed, unless the spouses are separated and a joint petition is not filed. An individual debtor engaged in business as a sole proprietor, partner, family farmer, or self-employed professional, should provide the information requested on this statement concerning all such activities as well as the individual's personal affairs. Questions 1 - 18 are to be completed by all debtors. Debtors that are or have been in business, as defined below, also must complete Questions 19 - 25. If the answer to an applicable question is "None," mark the box labeled "None." If additional space is needed for the answer to any question, use and attach a separate sheet properly identified with the case name, case number (if known), and the number of the question.

DEFINITIONS "In business." A debtor is "in business" for the purpose of this form if the debtor is a corporation or partnership. An individual debtor is "in business" for the purpose of this form if the debtor is or has been, within the six years immediately preceding the filing of this bankruptcy case, any of the following: an officer, director, managing executive, or owner of 5 percent or more of the voting or equity securities of a corporation; a partner, other than a limited partner, of a partnership; a sole proprietor or self-employed. "Insider." The term "insider" includes but is not limited to: relatives of the debtor; general partners of the debtor and their relatives; corporations of which the debtor is an officer, director, or person in control; officers, directors, and any owner of 5 percent or more of the voting or equity securities of a corporate debtor and their relatives; affiliates of the debtor and insiders of such affiliates; any managing agent of the debtor. 11 U.S.C. § 101. _______________________________________ 1.
None

Income from employment or operation of business

State the gross amount of income the debtor has received from employment, trade, or profession, or from operation of the debtor's business from the beginning of this calendar year to the date this case was commenced. State also the gross amounts received during the two years immediately preceding this calendar year. (A debtor that maintains, or has maintained, financial records on the basis of a fiscal rather than a calendar year may report fiscal year income. Identify the beginning and ending dates of the debtor's fiscal year.) If a joint petition is filed, state income for each spouse separately. (Married debtors filing under chapter 12 or chapter 13 must state income of both spouses whether or not a joint petition is filed, unless the spouses are separated and a joint petition is not filed.) AMOUNT SOURCE (if more than one)

2.
None

Income other than from employment or operation of business

State the amount of income received by the debtor other than from employment, trade, profession, or operation of the debtor's business during the two years immediately preceding the commencement of this case. Give particulars. If a joint petition is filed, state income for each spouse separately. (Married debtors filing under chapter 12 or chapter 13 must state income for each spouse whether or not a joint petition is filed, unless the spouses are separated and a joint petition is not filed.) AMOUNT SOURCE

________________________________________________________________________________________________ 3.
None

Payments to creditors List all payments on loans, installment purchases of goods or services, and other debts, aggregating more than $600 to any creditor, made within 90 days immediately preceding the commencement of this case. (Married debtors filing under chapter 12 or chapter 13 must include payments by either or both spouses whether or not a joint petition is filed, unless the spouses are separated and a joint petition is not filed.) DATES OF PAYMENTS AMOUNT PAID AMOUNT STILL OWING

a.

NAME AND ADDRESS OF CREDITOR

________________________________________________________________________________________________
None

b.

List all payments made within one year immediately preceding the commencement of this case to or for the benefit of creditors who are or were insiders. (Married debtors filing under chapter 12 or chapter 13 must include payments by either or both spouses whether or not a joint petition is filed, unless the spouses are separated and a joint petition is not filed.) DATE OF PAYMENT AMOUNT PAID AMOUNT STILL OWING

NAME AND ADDRESS OF CREDITOR AND RELATIONSHIP TO DEBTOR

________________________________________________________________________________________________ 4. Suits and administrative proceedings, executions, garnishments and attachments
None

a.

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

CAPTION OF SUIT AND CASE NUMBER

NATURE OF PROCEEDING

None

b.

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

NAME AND ADDRESS OF PERSON FOR WHOSE BENEFIT PROPERTY WAS SEIZED

DATE OF SEIZURE

________________________________________________________________________________________________ 5.
None

Repossessions, foreclosures and returns

List all property that has been repossessed by a creditor, sold at a foreclosure sale, transferred through a deed in lieu of foreclosure or returned to the seller, within one year immediately preceding the commencement of this case. (Married debtors filing under chapter 12 or chapter 13 must include information concerning property of either or both spouses whether or not a joint petition is filed, unless the spouses are separated and a joint petition is not filed.) DATE OF REPOSSESSION, FORECLOSURE SALE, TRANSFER OR RETURN DESCRIPTION AND VALUE OF PROPERTY

NAME AND ADDRESS OF CREDITOR OR SELLER

________________________________________________________________________________________________ 6.
None

Assignments and receiverships Describe any assignment of property for the benefit of creditors made within 120 days immediately preceding the commencement of this case. (Married debtors filing under chapter 12 or chapter 13 must include any assignment by either or both spouses whether or not a joint petition is filed, unless the spouses are separated and a joint petition is not filed.) TERMS OF ASSIGNMENT OR SETTLEMENT

a.

NAME AND ADDRESS OF ASSIGNEE

DATE OF ASSIGNMENT

________________________________________________________________________________________________
None

b.

List all property which has been in the hands of a custodian, receiver, or court-appointed official within one year immediately preceding the commencement of this case. (Married debtors filing under chapter 12 or chapter 13 must include information concerning property of either or both spouses whether or not a joint petition is filed, unless the spouses are separated and a joint petition is not filed.) NAME AND LOCATION OF COURT CASE TITLE & NUMBER DESCRIPTION AND VALUE OF PROPERTY

NAME AND ADDRESS OF CUSTODIAN

DATE OF ORDER

7.
None

Gifts

List all gifts or charitable contributions made within one year immediately preceding the commencement of this case except ordinary and usual gifts to family members aggregating less than $200 in value per individual family member and charitable contributions aggregating less than $100 per recipient. (Married debtors filing under chapter 12 or chapter 13 must include gifts or contributions by either or both spouses whether or not a joint petition is filed, unless the spouses are separated and a joint petition is not filed.) NAME AND ADDRESS OF PERSON OR ORGANIZATION RELATIONSHIP TO DEBTOR, IF ANY DESCRIPTION AND VALUE OF GIFT

DATE OF GIFT

________________________________________________________________________________________________ 8.
None

Losses

List all losses from fire, theft, other casualty or gambling within one year immediately preceding the commencement of this case or since the commencement of this case. (Married debtors filing under chapter 12 or chapter 13 must include losses by either or both spouses whether or not a joint petition is filed, unless the spouses are separated and a joint petition is not filed.) DESCRIPTION AND VALUE OF PROPERTY DESCRIPTION OF CIRCUMSTANCES AND, IF LOSS WAS COVERED IN WHOLE OR IN PART BY INSURANCE, GIVE PARTICULARS

DATE OF LOSS

________________________________________________________________________________________________ 9.
None

Payments related to debt counseling or bankruptcy

List all payments made or property transferred by or on behalf of the debtor to any persons, including attorneys, for consultation concerning debt consolidation, relief under the bankruptcy law or preparation of a petition in bankruptcy within one year immediately preceding the commencement of this case. DATE OF PAYMENT, NAME OF PAYOR IF OTHER THAN DEBTOR AMOUNT OF MONEY OR DESCRIPTION AND VALUE OF PROPERTY

NAME AND ADDRESS OF PAYEE

________________________________________________________________________________________________ 10. Other transfers
None

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

NAME AND ADDRESS OF TRANSFEREE, RELATIONSHIP TO DEBTOR

DATE

11. Closed financial accounts
None

List all financial accounts and instruments held in the name of the debtor or for the benefit of the debtor which were closed, sold, or otherwise transferred within one year immediately preceding the commencement of this case. Include checking, savings, or other financial accounts, certificates of deposit, or other instruments; shares and share accounts held in banks, credit unions, pension funds, cooperatives, associations, brokerage houses and other financial institutions. (Married debtors filing under chapter 12 or chapter 13 must include information concerning accounts or instruments held by or for either or both spouses whether or not a joint petition is filed, unless the spouses are separated and a joint petition is not filed.) TYPE OF ACCOUNT, LAST FOUR DIGITS OF ACCOUNT NUMBER, AND AMOUNT OF FINAL BALANCE AMOUNT AND DATE OF SALE OR CLOSING

NAME AND ADDRESS OF INSTITUTION

________________________________________________________________________________________________ 12. Safe deposit boxes
None

List each safe deposit or other box or depository in which the debtor has or had securities, cash, or other valuables within one year immediately preceding the commencement of this case. (Married debtors filing under chapter 12 or chapter 13 must include boxes or depositories of either or both spouses whether or not a joint petition is filed, unless the spouses are separated and a joint petition is not filed.) NAME AND ADDRESS OF BANK OR OTHER DEPOSITORY NAMES AND ADDRESSES OF THOSE WITH ACCESS TO BOX OR DEPOSITORY DESCRIPTION OF CONTENTS DATE OF TRANSFER OR SURRENDER, IF ANY

________________________________________________________________________________________________ 13. Setoffs
None

List all setoffs made by any creditor, including a bank, against a debt or deposit of the debtor within 90 days preceding the commencement of this case. (Married debtors filing under chapter 12 or chapter 13 must include information concerning either or both spouses whether or not a joint petition is filed, unless the spouses are separated and a joint petition is not filed.) DATE OF SETOFF AMOUNT OF SETOFF

NAME AND ADDRESS OF CREDITOR

________________________________________________________________________________________________ 14. Property held for another person
None

List all property owned by another person that the debtor holds or controls.

NAME AND ADDRESS OF OWNER

DESCRIPTION AND VALUE OF PROPERTY

LOCATION OF PROPERTY

15. Prior address of debtor
None

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

________________________________________________________________________________________________ 16. Spouses and Former Spouses
None

If the debtor resides or resided in a community property state, commonwealth, or territory (including Alaska, Arizona, California, Idaho, Louisiana, Nevada, New Mexico, Puerto Rico, Texas, Washington, or Wisconsin) within the sixyear period immediately preceding the commencement of the case, identify the name of the debtor's spouse and of any former spouse who resides or resided with the debtor in the community property state. NAME

________________________________________________________________________________________________ 17. Environmental Information. For the purpose of this question, the following definitions apply: "Environmental Law" means any federal, state, or local statute or regulation regulating pollution, contamination, releases of hazardous or toxic substances, wastes or material into the air, land, soil, surface water, groundwater, or other medium, including, but not limited to, statutes or regulations regulating the cleanup of these substances, wastes, or material. "Site" means any location, facility, or property as defined under any Environmental Law, whether or not presently or formerly owned or operated by the debtor, including, but not limited to, disposal sites. "Hazardous Material" means anything defined as a hazardous waste, hazardous substance, toxic substance, hazardous material, pollutant, or contaminant or similar term under an Environmental Law ________________________________________________________________________________________________
None

a.

List the name and address of every site for which the debtor has received notice in writing by a governmental unit that it may be liable or potentially liable under or in violation of an Environmental Law. Indicate the governmental unit, the date of the notice, and, if known, the Environmental Law: NAME AND ADDRESS OF GOVERNMENTAL UNIT DATE OF NOTICE ENVIRONMENTAL LAW

SITE NAME AND ADDRESS

________________________________________________________________________________________________
None

b.

List the name and address of every site for which the debtor provided notice to a governmental unit of a release of Hazardous Material. Indicate the governmental unit to which the notice was sent and the date of the notice. NAME AND ADDRESS OF GOVERNMENTAL UNIT DATE OF NOTICE ENVIRONMENTAL LAW

SITE NAME AND ADDRESS

None

c.

List all judicial or administrative proceedings, including settlements or orders, under any Environmental Law with respect to which the debtor is or was a party. Indicate the name and address of the governmental unit that is or was a party to the proceeding, and the docket number. DOCKET NUMBER STATUS OR DISPOSITION

NAME AND ADDRESS OF GOVERNMENTAL UNIT

________________________________________________________________________________________________ 18 . Nature, location and name of business
None

a.

If the debtor is an individual, list the names, addresses, taxpayer identification numbers, nature of the businesses, and beginning and ending dates of all businesses in which the debtor was an officer, director, partner, or managing executive of a corporation, partnership, sole proprietorship, or was a self-employed professional within the six years immediately preceding the commencement of this case, or in which the debtor owned 5 percent or more of the voting or equity securities within the six years immediately preceding the commencement of this case. If the debtor is a partnership, list the names, addresses, taxpayer identification numbers, nature of the businesses, and beginning and ending dates of all businesses in which the debtor was a partner or owned 5 percent or more of the voting or equity securities, within the six years immediately preceding the commencement of this case. If the debtor is a corporation, list the names, addresses, taxpayer identification numbers, nature of the businesses, and beginning and ending dates of all businesses in which the debtor was a partner or owned 5 percent or more of the voting or equity securities within the six years immediately preceding the commencement of this case. LAST FOUR DIGITS OF TAXPAYER I.D. NUMBER

NAME

ADDRESS

NATURE OF BUSINESS

BEGINNING AND ENDING DATES

________________________________________________________________________________________________
None

b.

Identify any business listed in response to subdivision a., above, that is "single asset real estate" as defined in 11 U.S.C. § 101. ADDRESS

NAME

________________________________________________________________________________________________ The following questions are to be completed by every debtor that is a corporation or partnership and by any individual debtor who is or has been, within the six years immediately preceding the commencement of this case, any of the following: an officer, director, managing executive, or owner of more than 5 percent of the voting or equity securities of a corporation; a partner, other than a limited partner, of a partnership; a sole proprietor or otherwise self-employed. (An individual or joint debtor should complete this portion of the statement only if the debtor is or has been in business, as defined above, within the six years immediately preceding the commencement of this case. A debtor who has not been in business within those six years should go directly to the signature page.)

19. Books, records and financial statements
None

a.

List all bookkeepers and accountants who within the two years immediately preceding the filing of this bankruptcy case kept or supervised the keeping of books of account and records of the debtor. DATES SERVICES RENDERED

NAME AND ADDRESS

________________________________________________________________________________________________
None

b.

List all firms or individuals who within the two years immediately preceding the filing of this bankruptcy case have audited the books of account and records, or prepared a financial statement of the debtor. ADDRESS DATES SERVICES RENDERED

NAME

________________________________________________________________________________________________
None

c.

List all firms or individuals who at the time of the commencement of this case were in possession of the books of account and records of the debtor. If any of the books of account and records are not available, explain. ADDRESS

NAME

________________________________________________________________________________________________
None

d.

List all financial institutions, creditors and other parties, including mercantile and trade agencies, to whom a financial statement was issued within the two years immediately preceding the commencement of this case by the debtor. DATE ISSUED

NAME AND ADDRESS

________________________________________________________________________________________________ 20. Inventories
None

a.

List the dates of the last two inventories taken of your property, the name of the person who supervised the taking of each inventory, and the dollar amount and basis of each inventory. DOLLAR AMOUNT OF INVENTORY (Specify cost, market or other basis)

DATE OF INVENTORY

INVENTORY SUPERVISOR

________________________________________________________________________________________________
None

b.

List the name and address of the person having possession of the records of each of the two inventories reported in a., above. NAME AND ADDRESSES OF CUSTODIAN OF INVENTORY RECORDS

DATE OF INVENTORY

21 . Current Partners, Officers, Directors and Shareholders
None

a.

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

NAME AND ADDRESS

________________________________________________________________________________________________
None

b.

If the debtor is a corporation, list all officers and directors of the corporation, and each stockholder who directly or indirectly owns, controls, or holds 5 percent or more of the voting or equity securities of the corporation. NATURE AND PERCENTAGE NAME AND ADDRESS TITLE OF STOCK OWNERSHIP

________________________________________________________________________________________________ 22 . Former partners, officers, directors and shareholders
None

a.

If the debtor is a partnership, list each member who withdrew from the partnership within one year immediately preceding the commencement of this case. ADDRESS DATE OF WITHDRAWAL

NAME

________________________________________________________________________________________________
None

b.

If the debtor is a corporation, list all officers, or directors whose relationship with the corporation terminated within one year immediately preceding the commencement of this case. TITLE DATE OF TERMINATION

NAME AND ADDRESS

________________________________________________________________________________________________ 23 . Withdrawals from a partnership or distributions by a corporation
None

If the debtor is a partnership or corporation, list all withdrawals or distributions credited or given to an insider, including compensation in any form, bonuses, loans, stock redemptions, options exercised and any other perquisite during one year immediately preceding the commencement of this case. NAME & ADDRESS OF RECIPIENT, RELATIONSHIP TO DEBTOR AMOUNT OF MONEY OR DESCRIPTION AND VALUE OF PROPERTY

DATE AND PURPOSE OF WITHDRAWAL

24. Tax Consolidation Group.
None

If the debtor is a corporation, list the name and federal taxpayer identification number of the parent corporation of any consolidated group for tax purposes of which the debtor has been a member at any time within the six-year period immediately preceding the commencement of the case. NAME OF PARENT CORPORATION LAST FOUR DIGITS OF TAXPAYER IDENTIFICATION NUMBER

________________________________________________________________________________________________ 25. Pension Funds.
None

If the debtor is not an individual, list the name and federal taxpayer identification number of any pension fund to which the debtor, as an employer, has been responsible for contributing at any time within the six-year period immediately preceding the commencement of the case. NAME OF PENSION FUND LAST FOUR DIGITS OF TAXPAYER IDENTIFICATION NUMBER

________________________________________________________________________________________________

* * * * * *

[If completed by an individual or individual and spouse] I declare under penalty of perjury that I have read the answers contained in the foregoing statement of financial affairs and any attachments thereto and that they are true and correct.

Date __________________________

Signature _____________________________________________ of Debtor Signature__________________ of Joint Debtor (if any)

Date __________________________

__________________________________________________________________________________________________________________________

[If completed on behalf of a partnership or corporation] I, declare under p enalty of pe rjury that I hav e read the ans wers contain ed in the foreg oing statem ent of financial affairs an d any attach ments th ereto and that the y are true and correct to the be st of my k nowled ge, informatio n and b elief.

Date __________________________

Signature __________________________________________________ _________________________________________________ Print Nam e and Title

[An in divid ual sig ning on b ehalf o f a partn ership or corp oratio n mu st ind icate p ositio n or rel ation ship to deb tor.]

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

----------------------------------------------------------------------------------------------------------------------------------------------------------CERTIFICATION AND SIGNATURE OF NON-ATTORNE Y BANKRUPTCY PETITION PREPARER (See 11 U.S.C. § 110) 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 debto r with a copy of this docu ment. _____________________________________________________ Printed or Typed Name of Bankruptcy Petition Preparer _________________________________ _________________________________ Address Names a nd Social S ecurity num bers of all othe r individu als who p repared or assis ted in prepa ring this do cumen t: If more than one person prepared this document, attach additional signed sheets conforming to the appropriate Official Form for each person. X _____________________________________________________ Signature of Bankruptcy Petition Preparer ____________________ Date _____________________________ Social Security No. (Required by 1 1 U.S .C. § 1 10(c).)

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