Free Packet of Official Forms ( - Utah


File Size: 603.0 kB
Pages: 38
Date: December 15, 2008
File Format: PDF
State: Utah
Category: Bankruptcy
Author: AO User
Word Count: 12,659 Words, 87,583 Characters
Page Size: Letter (8 1/2" x 11")
URL

http://www.utb.uscourts.gov/clerks_office/forms/act2005/packetforms_12_07.pdf

Download Packet of Official Forms ( ( 603.0 kB)


Preview Packet of Official Forms (
B 1 (Official Form 1) (1/08) United States Bankruptcy Court Voluntary Petition Name of Debtor (if individual, enter Last, First, Middle): All Other Names used by the Debtor in the last 8 years (include married, maiden, and trade names): Last four digits of Soc. Sec. or Indvidual-Taxpayer I.D. (ITIN) No./Complete EIN (if more than one, state all): Street Address of Debtor (No. and Street, City, and State): Name of Joint Debtor (Spouse) (Last, First, Middle): All Other Names used by the Joint Debtor in the last 8 years (include married, maiden, and trade names): Last four digits of Soc. Sec. or Indvidual-Taxpayer I.D. (ITIN) No./Complete EIN (if more than one, state all): Street Address of Joint Debtor (No. and Street, City, and 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:

ZIP CODE

Mailing Address of Joint Debtor (if different from street address):

ZIP CODE Location of Principal Assets of Business Debtor (if different from street address above): Type of Debtor (Form of Organization) (Check one box.) Individual (includes Joint Debtors) See Exhibit D on page 2 of this form. Corporation (includes LLC and LLP) Partnership Other (If debtor is not one of the above entities, check this box and state type of entity below.) Nature of Business (Check one box.) Health Care Business Single Asset Real Estate as defined in 11 U.S.C. 101(51B) Railroad Stockbroker Commodity Broker Clearing Bank Other ___________________________________ Tax-Exempt Entity (Check box, if applicable.) Debtor is a tax-exempt organization under Title 26 of the United States Code (the Internal Revenue Code). 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 3A. Filing Fee waiver requested (applicable to chapter 7 individuals only). Must attach signed application for the court's consideration. See Official Form 3B.

ZIP CODE ZIP CODE Chapter of Bankruptcy Code Under Which the Petition is Filed (Check one box.) Chapter 7 Chapter 9 Chapter 11 Chapter 12 Chapter 13 Chapter 15 Petition for Recognition of a Foreign Main Proceeding Chapter 15 Petition for Recognition of a Foreign Nonmain Proceeding Nature of Debts (Check one box.) Debts are primarily consumer debts, defined in 11 U.S.C. 101(8) as "incurred by an individual primarily for a personal, family, or household purpose." Chapter 11 Debtors Debts are primarily business debts.

__________________________________________

Check one box: Debtor is a small business debtor as defined in 11 U.S.C. 101(51D). Debtor is not a small business debtor as defined in 11 U.S.C. 101(51D). Check if: Debtor's aggregate noncontingent liquidated debts (excluding debts owed to insiders or affiliates) are less than $2,190,000. ----------------------------------Check all applicable boxes: A plan is being filed with this petition. Acceptances of the plan were solicited prepetition from one or more classes of creditors, in accordance with 11 U.S.C. 1126(b).
THIS SPACE IS FOR COURT USE ONLY

Statistical/Administrative Information 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 1-49 50-99 100-199 200-999 1,0005,000 5,00110,000 10,00125,000 25,00150,000 50,001100,000 Over 100,000

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 $100,000,001 to $500 million $500,000,001 to $1 billion More than $1 billion

Estimated Liabilities $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 $100,000,001 to $500 million $500,000,001 to $1 billion More than $1 billion

B 1 (Official Form 1) (1/08) Name of Debtor(s): Voluntary Petition (This page must be completed and filed in every case.) All Prior Bankruptcy Cases Filed Within Last 8 Years (If more than two, attach additional sheet.) Location Case Number: Date Filed: Where Filed: Location Case Number: Date Filed: Where Filed: Pending Bankruptcy Case Filed by any Spouse, Partner, or Affiliate of this Debtor (If more than one, attach additional sheet.) Name of Debtor: Case Number: Date Filed: District: 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.) Relationship: Judge: Exhibit B (To be completed if debtor is an individual whose debts are primarily consumer debts.)

Page 2

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. I further certify that I have delivered to the debtor the notice required by 11 U.S.C. 342(b). X Signature of Attorney for Debtor(s) (Date)

Exhibit A is attached and made a part of this petition.

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.

Exhibit D (To be completed by every individual debtor. If a joint petition is filed, each spouse must complete and attach a separate Exhibit D.) Exhibit D completed and signed by the debtor is attached and made a part of this petition. If this is a joint petition: Exhibit D also completed and signed by the joint debtor is attached and made a part of this petition.
Information Regarding the Debtor - 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. Debtor is a debtor in a foreign proceeding and has its principal place of business or principal assets in the United States in this District, or has no principal place of business or assets in the United States but is a defendant in an action or proceeding [in a federal or state court] in this District, or the interests of the parties will be served in regard to the relief sought in this District.

Certification by a Debtor Who Resides as a Tenant of Residential Property (Check all applicable boxes.) Landlord has a judgment against the debtor for possession of debtor's residence. (If box checked, complete the following.)

(Name of landlord that obtained judgment)

(Address of landlord) Debtor claims that under applicable nonbankruptcy law, there are circumstances under which the debtor would be permitted to cure the entire monetary default that gave rise to the judgment for possession, after the judgment for possession was entered, and Debtor has included with this petition the deposit with the court of any rent that would become due during the 30-day period after the filing of the petition. Debtor certifies that he/she has served the Landlord with this certification. (11 U.S.C. 362(l)).

B 1 (Official Form) 1 (1/08) Voluntary Petition (This page must be completed and filed in every case.) 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. [If no attorney represents me and no bankruptcy petition preparer signs the petition] 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. X Signature of Debtor X Signature of Joint Debtor Telephone Number (if not represented by attorney)

Page 3 Name of Debtor(s): Signatures Signature of a Foreign Representative I declare under penalty of perjury that the information provided in this petition is true and correct, that I am the foreign representative of a debtor in a foreign proceeding, and that I am authorized to file this petition. (Check only one box.) I request relief in accordance with chapter 15 of title 11, United States Code. Certified copies of the documents required by 11 U.S.C. 1515 are attached. Pursuant to 11 U.S.C. 1511, I request relief in accordance with the chapter of title 11 specified in this petition. A certified copy of the order granting recognition of the foreign main proceeding is attached. X (Signature of Foreign Representative)

(Printed Name of Foreign Representative)

Date Date Signature of Attorney* X Signature of Attorney for Debtor(s) Printed Name of Attorney for Debtor(s) Firm Name Address Signature of Non-Attorney Bankruptcy Petition Preparer I declare under penalty of perjury that: (1) I am a bankruptcy petition preparer as defined in 11 U.S.C. 110; (2) I prepared this document for compensation and have provided the debtor with a copy of this document and the notices and information required under 11 U.S.C. 110(b), 110(h), and 342(b); and, (3) if rules or guidelines have been promulgated pursuant to 11 U.S.C. 110(h) setting a maximum fee for services chargeable by bankruptcy petition preparers, I have given the debtor notice of the maximum amount before preparing any document for filing for a debtor or accepting any fee from the debtor, as required in that section. Official Form 19 is attached.

Telephone Number Date *In a case in which 707(b)(4)(D) applies, this signature also constitutes a certification that the attorney has no knowledge after an inquiry that the information in the schedules is incorrect. 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 the relief in accordance with the chapter of title 11, United States Code, specified in this petition. X Signature of Authorized Individual Printed Name of Authorized Individual Title of Authorized Individual Date X

Printed Name and title, if any, of Bankruptcy Petition Preparer Social-Security number (If the bankruptcy petition preparer is not an individual, state the Social-Security number of the officer, principal, responsible person or partner of the bankruptcy petition preparer.) (Required by 11 U.S.C. 110.)

Address

Date Signature of bankruptcy petition preparer or officer, principal, responsible person, or partner whose Social-Security number is provided above. Names and Social-Security numbers of all other individuals who prepared or assisted in preparing this document unless the bankruptcy petition preparer is not an individual. If more than one person prepared this document, attach additional sheets conforming to the appropriate official form for each person. 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.

Reset

Save As...

Print

B6 Declaration (Official Form 6 - Declaration) (12/07) In re _________________________________________ , Debtor Case No. ______________________________ (if known)

DECLARATION CONCERNING DEBTOR'S SCHEDULES
DECLARATION UNDER PENALTY OF PERJURY BY INDIVIDUAL DEBTOR

I declare under penalty of perjury that I have read the foregoing summary and schedules, consisting of _____ sheets, and that they are true and correct to the best of my knowledge, information, and belief.

Date __________________________________

Signature: ________________________________________________ Debtor Signature: ________________________________________________
(Joint Debtor, if any) [If joint case, both spouses must sign.]

Date __________________________________

------------------------------------------------------------------------------------------------------------------------------------------DECLARATION AND SIGNATURE OF NON-ATTORNEY BANKRUPTCY PETITION PREPARER (See 11 U.S.C. 110)

I declare under penalty of perjury that: (1) I am a bankruptcy petition preparer as defined in 11 U.S.C. 110; (2) I prepared this document for compensation and have provided the debtor with a copy of this document and the notices and information required under 11 U.S.C. 110(b), 110(h) and 342(b); and, (3) if rules or guidelines have been promulgated pursuant to 11 U.S.C. 110(h) setting a maximum fee for services chargeable by bankruptcy petition preparers, I have given the debtor notice of the maximum amount before preparing any document for filing for a debtor or accepting any fee from the debtor, as required by that section. _____________________________________________________ Printed or Typed Name and Title, if any, of Bankruptcy Petition Preparer _____________________________ Social Security No. (Required by 11 U.S.C. 110.)

If the bankruptcy petition preparer is not an individual, state the name, title (if any), address, and social security number of the officer, principal, responsible person, or partner who signs this document. _________________________________ _________________________________ _________________________________ Address X _____________________________________________________ Signature of Bankruptcy Petition Preparer ____________________ Date

Names and Social Security numbers of all other individuals who prepared or assisted in preparing this document, unless the bankruptcy petition preparer is not an individual: If more than one person prepared this document, attach additional signed sheets conforming to the appropriate Official Form for each person.

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. --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

DECLARATION UNDER PENALTY OF PERJURY ON BEHALF OF A CORPORATION OR PARTNERSHIP

I, the __________________________________ [the president or other officer or an authorized agent of the corporation or a member or an authorized agent of the partnership ] of the ___________________________________ [corporation or partnership] named as debtor in this case, declare under penalty of perjury that I have read the foregoing summary and schedules, consisting of ___ sheets (Total shown on summary page plus 1), and that they are true and correct to the best of my knowledge, information, and belief.

Date ______________________________________ Signature: _____________________________________________________________ ____________________________________________________________ [Print or type name of individual signing on behalf of debtor.] [An individual signing on behalf of a partnership or corporation must indicate position or relationship to debtor.] ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------Penalty for making a false statement or concealing property: Fine of up to $500,000 or imprisonment for up to 5 years or both. 18 U.S.C. 152 and 3571.

B 1D (Official Form 1, Exhibit D) (12/08)

UNITED STATES BANKRUPTCY COURT
__________ District of __________

In re__________________________
Debtor

Case No._____________
(if known)

EXHIBIT D - INDIVIDUAL DEBTOR'S STATEMENT OF COMPLIANCE WITH CREDIT COUNSELING REQUIREMENT Warning: You must be able to check truthfully one of the five statements regarding credit counseling listed below. If you cannot do so, you are not eligible to file a bankruptcy case, and the court can dismiss any case you do file. If that happens, you will lose whatever filing fee you paid, and your creditors will be able to resume collection activities against you. If your case is dismissed and you file another bankruptcy case later, you may be required to pay a second filing fee and you may have to take extra steps to stop creditors' collection activities. Every individual debtor must file this Exhibit D. If a joint petition is filed, each spouse must complete and file a separate Exhibit D. Check one of the five statements below and attach any documents as directed. ' 1. Within the 180 days before the filing of my bankruptcy case, I received a briefing from a credit counseling agency approved by the United States trustee or bankruptcy administrator that outlined the opportunities for available credit counseling and assisted me in performing a related budget analysis, and I have a certificate from the agency describing the services provided to me. Attach a copy of the certificate and a copy of any debt repayment plan developed through the agency. ' 2. Within the 180 days before the filing of my bankruptcy case, I received a briefing from a credit counseling agency approved by the United States trustee or bankruptcy administrator that outlined the opportunities for available credit counseling and assisted me in performing a related budget analysis, but I do not have a certificate from the agency describing the services provided to me. You must file a copy of a certificate from the agency describing the services provided to you and a copy of any debt repayment plan developed through the agency no later than 15 days after your bankruptcy case is filed.

B 1D (Official Form 1, Exh. D) (12/08) Cont.

Page 2

' 3. I certify that I requested credit counseling services from an approved agency but was unable to obtain the services during the five days from the time I made my request, and the following exigent circumstances merit a temporary waiver of the credit counseling requirement so I can file my bankruptcy case now. [Summarize exigent circumstances here.] ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________

If your certification is satisfactory to the court, you must still obtain the credit counseling briefing within the first 30 days after you file your bankruptcy petition and promptly file a certificate from the agency that provided the counseling, together with a copy of any debt management plan developed through the agency. Failure to fulfill these requirements may result in dismissal of your case. Any extension of the 30-day deadline can be granted only for cause and is limited to a maximum of 15 days. Your case may also be dismissed if the court is not satisfied with your reasons for filing your bankruptcy case without first receiving a credit counseling briefing. ' 4. I am not required to receive a credit counseling briefing because of: [Check the applicable statement.] [Must be accompanied by a motion for determination by the court.] ' Incapacity. (Defined in 11 U.S.C. 109(h)(4) as impaired by reason of mental illness or mental deficiency so as to be incapable of realizing and making rational decisions with respect to financial responsibilities.); ' Disability. (Defined in 11 U.S.C. 109(h)(4) as physically impaired to the extent of being unable, after reasonable effort, to participate in a credit counseling briefing in person, by telephone, or through the Internet.); ' Active military duty in a military combat zone. ' 5. The United States trustee or bankruptcy administrator has determined that the credit counseling requirement of 11 U.S.C. ' 109(h) does not apply in this district.

I certify under penalty of perjury that the information provided above is true and correct.

Signature of Debtor: ________________________ Date: _________________

Reset

Save As...

Print

B6 Summary (Official Form 6 - Summary) (12/07)

United States Bankruptcy Court
_______________ District Of ______________
In re ___________________________________, Debtor Case No. ___________________ Chapter ____________

SUMMARY OF SCHEDULES
Indicate as to each schedule whether that schedule is attached and state the number of pages in each. Report the totals from Schedules A, B, D, E, F, I, and J in the boxes provided. Add the amounts from Schedules A and B to determine the total amount of the debtor's assets. Add the amounts of all claims from Schedules D, E, and F to determine the total amount of the debtor's liabilities. Individual debtors also must complete the "Statistical Summary of Certain Liabilities and Related Data" if they file a case under chapter 7, 11, or 13.
ATTACHED (YES/NO)

NAME OF SCHEDULE A - Real Property

NO. OF SHEETS $

ASSETS

LIABILITIES

OTHER

B - Personal Property

$

C - Property Claimed as Exempt D - Creditors Holding Secured Claims E - Creditors Holding Unsecured Priority Claims (Total of Claims on Schedule E) F - Creditors Holding Unsecured Nonpriority Claims $

$

$

G - Executory Contracts and Unexpired Leases

H - Codebtors

I - Current Income of Individual Debtor(s) J - Current Expenditures of Individual Debtors(s) TOTAL $ $

$

$

Form 6 - Statistical Summary (12/07)

United States Bankruptcy Court
_______________ District Of ______________

In re ___________________________________, Debtor

Case No. ___________________ Chapter ____________

STATISTICAL SUMMARY OF CERTAIN LIABILITIES AND RELATED DATA (28 U.S.C. 159)
If you are an individual debtor whose debts are primarily consumer debts, as defined in 101(8) of the Bankruptcy Code (11 U.S.C. 101(8)), filing a case under chapter 7, 11 or 13, you must report all information requested below.

Q Check this box if you are an individual debtor whose debts are NOT primarily consumer debts. You are not required to report any information here.

This information is for statistical purposes only under 28 U.S.C. 159.
Summarize the following types of liabilities, as reported in the Schedules, and total them.

Type of Liability Domestic Support Obligations (from Schedule E) Taxes and Certain Other Debts Owed to Governmental Units (from Schedule E) Claims for Death or Personal Injury While Debtor Was Intoxicated (from Schedule E) (whether disputed or undisputed) Student Loan Obligations (from Schedule F) Domestic Support, Separation Agreement, and Divorce Decree Obligations Not Reported on Schedule E Obligations to Pension or Profit-Sharing, and Other Similar Obligations (from Schedule F) TOTAL State the following: Average Income (from Schedule I, Line 16) Average Expenses (from Schedule J, Line 18) Current Monthly Income (from Form 22A Line 12; OR, Form 22B Line 11; OR, Form 22C Line 20 )

Amount $ $ $ $ $ $ $

$ $ $

State the following:
1. Total from Schedule D, "UNSECURED PORTION, IF ANY" column 2. Total from Schedule E, "AMOUNT ENTITLED TO PRIORITY" column. 3. Total from Schedule E, "AMOUNT NOT ENTITLED TO PRIORITY, IF ANY" column 4. Total from Schedule F 5. Total of non-priority unsecured debt (sum of 1, 3, and 4)

$ $ $ $ $

B6A (Official Form 6A) (12/07)
In re _____________________________________________, Debtor Case No. ______________________________ (If known)

SCHEDULE A - REAL PROPERTY
Except as directed below, list all real property in which the debtor has any legal, equitable, or future interest, including all property owned as a cotenant, community property, or in which the debtor has a life estate. Include any property in which the debtor holds rights and powers exercisable for the debtor's own benefit. If the debtor is married, state whether the husband, wife, both, or the marital community own the property by placing an "H," "W," "J," or "C" in the column labeled "Husband, Wife, Joint, or Community." If the debtor holds no interest in real property, write "None" under "Description and Location of Property." Do not include interests in executory contracts and unexpired leases on this schedule. List them in Schedule G - Executory Contracts and Unexpired Leases. If an entity claims to have a lien or hold a secured interest in any property, state the amount of the secured claim. See Schedule D. If no entity claims to hold a secured interest in the property, write "None" in the column labeled "Amount of Secured Claim." If the debtor is an individual or if a joint petition is filed, state the amount of any exemption claimed in the property only in Schedule C - Property Claimed as Exempt.

DESCRIPTION AND LOCATION OF PROPERTY

NATURE OF DEBTOR'S INTEREST IN PROPERTY

CURRENT VALUE OF DEBTOR'S INTEREST IN PROPERTY, WITHOUT DEDUCTING ANY SECURED CLAIM OR EXEMPTION

AMOUNT OF SECURED CLAIM

Total' (Report also on Summary of Schedules.)

B6B (Official Form 6B) (12/07)
In re _______________________________________________, Debtor Case No. _________________________ (If known)

SCHEDULE B - PERSONAL PROPERTY
Except as directed below, list all personal property of the debtor of whatever kind. If the debtor has no property in one or more of the categories, place an "x" in the appropriate position in the column labeled "None." If additional space is needed in any category, attach a separate sheet properly identified with the case name, case number, and the number of the category. If the debtor is married, state whether the husband, wife, both, or the marital community own the property by placing an "H," "W," "J," or "C" in the column labeled "Husband, Wife, Joint, or Community." If the debtor is an individual or a joint petition is filed, state the amount of any exemptions claimed only in Schedule C - Property Claimed as Exempt. Do not list interests in executory contracts and unexpired leases on this schedule. List them in Schedule G - Executory Contracts and Unexpired Leases. If the property is being held for the debtor by someone else, state that person's name and address under "Description and Location of Property." If the property is being held for a minor child, simply state the child's initials and the name and address of the child's parent or guardian, such as "A.B., a minor child, by John Doe, guardian." Do not disclose the child's name. See, 11 U.S.C. 112 and Fed. R. Bankr. P. 1007(m).
CURRENT VALUE OF DEBTOR'S INTEREST IN PROPERTY, WITHOUT DEDUCTING ANY SECURED CLAIM OR EXEMPTION

TYPE OF PROPERTY

N O N E

DESCRIPTION AND LOCATION OF PROPERTY

1. Cash on hand. 2. Checking, savings or other financial accounts, certificates of deposit or shares in banks, savings and loan, thrift, building and loan, and homestead associations, or credit unions, brokerage houses, or cooperatives. 3. Security deposits with public utilities, telephone companies, landlords, and others. 4. Household goods and furnishings, including audio, video, and computer equipment. 5. Books; pictures and other art objects; antiques; stamp, coin, record, tape, compact disc, and other collections or collectibles. 6. Wearing apparel. 7. Furs and jewelry. 8. Firearms and sports, photographic, and other hobby equipment. 9. Interests in insurance policies. Name insurance company of each policy and itemize surrender or refund value of each. 10. Annuities. Itemize and name each issuer. 11. Interests in an education IRA as defined in 26 U.S.C. 530(b)(1) or under a qualified State tuition plan as defined in 26 U.S.C. 529(b)(1). Give particulars. (File separately the record(s) of any such interest(s). 11 U.S.C. 521(c).)

B6B (Official Form 6B) (12/07) -- Cont.

In re ______________________________________________, Debtor

Case No. _________________________ (If known)

SCHEDULE B - PERSONAL PROPERTY
(Continuation Sheet)
CURRENT VALUE OF DEBTOR'S INTEREST IN PROPERTY, WITHOUT DEDUCTING ANY SECURED CLAIM OR EXEMPTION

TYPE OF PROPERTY

N O N E

DESCRIPTION AND LOCATION OF PROPERTY

12. Interests in IRA, ERISA, Keogh, or other pension or profit sharing plans. Give particulars. 13. Stock and interests in incorporated and unincorporated businesses. Itemize. 14. Interests in partnerships or joint ventures. Itemize. 15. Government and corporate bonds and other negotiable and nonnegotiable instruments. 16. Accounts receivable. 17. Alimony, maintenance, support, and property settlements to which the debtor is or may be entitled. Give particulars. 18. Other liquidated debts owed to debtor including tax refunds. Give particulars. 19. Equitable or future interests, life estates, and rights or powers exercisable for the benefit of the debtor other than those listed in Schedule A Real Property. 20. Contingent and noncontingent interests in estate of a decedent, death benefit plan, life insurance policy, or trust. 21. Other contingent and unliquidated claims of every nature, including tax refunds, counterclaims of the debtor, and rights to setoff claims. Give estimated value of each.

B6B (Official Form 6B) (12/07) -- Cont.
In re _________________________________________________, Debtor Case No. _________________________ (If known)

SCHEDULE B - PERSONAL PROPERTY
(Continuation Sheet)

TYPE OF PROPERTY

N O N E

DESCRIPTION AND LOCATION OF PROPERTY

CURRENT VALUE OF DEBTOR'S INTEREST IN PROPERTY, WITHOUT DEDUCTING ANY SECURED CLAIM OR EXEMPTION

22. Patents, copyrights, and other intellectual property. Give particulars. 23. Licenses, franchises, and other general intangibles. Give particulars. 24. Customer lists or other compilations containing personally identifiable information (as defined in 11 U.S.C. 101(41A)) provided to the debtor by individuals in connection with obtaining a product or service from the debtor primarily for personal, family, or household purposes. 25. Automobiles, trucks, trailers, and other vehicles and accessories. 26. Boats, motors, and accessories. 27. Aircraft and accessories. 28. Office equipment, furnishings, and supplies.

29. Machinery, fixtures, equipment, and supplies used in business.

30. Inventory.

31. Animals.

32. Crops - growing or harvested. Give particulars.

33. Farming equipment and implements.

34. Farm supplies, chemicals, and feed. 35. Other personal property of any kind not already listed. Itemize.

__________continuation sheets attached

Total'

$

(Include amounts from any continuation sheets attached. Report total also on Summary of Schedules.)

B6C (Official Form 6C) (12/07)
In re ____________________________________________, Debtor Case No. _________________________ (If known)

SCHEDULE C - PROPERTY CLAIMED AS EXEMPT
Debtor claims the exemptions to which debtor is entitled under: (Check one box) G 11 U.S.C. 522(b)(2) G 11 U.S.C. 522(b)(3)

G Check if debtor claims a homestead exemption that exceeds $136,875.

DESCRIPTION OF PROPERTY

SPECIFY LAW PROVIDING EACH EXEMPTION

VALUE OF CLAIMED EXEMPTION

CURRENT VALUE OF PROPERTY WITHOUT DEDUCTING EXEMPTION

B6D (Official Form 6D) (12/07) In re ____________________________________, Debtor Case No. __________________________________ (If known)

SCHEDULE D - CREDITORS HOLDING SECURED CLAIMS
State the name, mailing address, including zip code, and last four digits of any account number of all entities holding claims secured by property of the debtor as of the date of filing of the petition. The complete account number of any account the debtor has with the creditor is useful to the trustee and the creditor and may be provided if the debtor chooses to do so. List creditors holding all types of secured interests such as judgment liens, garnishments, statutory liens, mortgages, deeds of trust, and other security interests. List creditors in alphabetical order to the extent practicable. If a minor child is the creditor, state the child's initials and the name and address of the child's parent or guardian, such as "A.B., a minor child, by John Doe, guardian." Do not disclose the child's name. See, 11 U.S.C. 112 and Fed. R. Bankr. P. 1007(m). If all secured creditors will not fit on this page, use the continuation sheet provided. If any entity other than a spouse in a joint case may be jointly liable on a claim, place an "X" in the column labeled "Codebtor," include the entity on the appropriate schedule of creditors, and complete Schedule H Codebtors. If a joint petition is filed, state whether the husband, wife, both of them, or the marital community may be liable on each claim by placing an "H," "W," "J," or "C" in the column labeled "Husband, Wife, Joint, or Community." If the claim is contingent, place an "X" in the column labeled "Contingent." If the claim is unliquidated, place an "X" in the column labeled "Unliquidated." If the claim is disputed, place an "X" in the column labeled "Disputed." (You may need to place an "X" in more than one of these three columns.) Total the columns labeled "Amount of Claim Without Deducting Value of Collateral" and "Unsecured Portion, if Any" in the boxes labeled "Total(s)" on the last sheet of the completed schedule. Report the total from the column labeled "Amount of Claim Without Deducting Value of Collateral" also on the Summary of Schedules and, if the debtor is an individual with primarily consumer debts, report the total from the column labeled "Unsecured Portion, if Any" on the Statistical Summary of Certain Liabilities and Related Data.



Check this box if debtor has no creditors holding secured claims to report on this Schedule D.

HUSBAND, WIFE, JOINT, OR COMMUNITY

CONTINGENT

CODEBTOR

ACCOUNT NO.

VALUE $ ACCOUNT NO.

VALUE $ ACCOUNT NO.

____continuation sheets
attached

VALUE $ Subtotal (Total of this page) Total (Use only on last page)

DISPUTED

CREDITOR'S NAME AND MAILING ADDRESS INCLUDING ZIP CODE AND AN ACCOUNT NUMBER (See Instructions Above.)

DATE CLAIM WAS INCURRED, NATURE OF LIEN , AND DESCRIPTION AND VALUE OF PROPERTY SUBJECT TO LIEN

UNLIQUIDATED

AMOUNT OF CLAIM WITHOUT DEDUCTING VALUE OF COLLATERAL

UNSECURED PORTION, IF ANY

$ $
(Report also on Summary of Schedules.)

$ $
(If applicable, report also on Statistical Summary of Certain Liabilities and Related Data.)

B6D (Official Form 6D) (12/07) Cont. In re ____________________________________, Debtor Case No. __________________________________ (if known)

2

SCHEDULE D - CREDITORS HOLDING SECURED CLAIMS
(Continuation Sheet)

HUSBAND, WIFE, JOINT, OR COMMUNITY

CONTINGENT

CODEBTOR

CREDITOR'S NAME AND MAILING ADDRESS INCLUDING ZIP CODE AND AN ACCOUNT NUMBER (See Instructions Above.)

DATE CLAIM WAS INCURRED, NATURE OF LIEN , AND DESCRIPTION AND VALUE OF PROPERTY SUBJECT TO LIEN

UNLIQUIDATED

ACCOUNT NO.

VALUE $ ACCOUNT NO.

VALUE $ ACCOUNT NO.

VALUE $ ACCOUNT NO.

VALUE $ ACCOUNT NO.

VALUE $ Sheet no.___of___continuation sheets attached to Schedule of Creditors Holding Secured Claims Subtotal (s) (Total(s) of this page) Total(s) (Use only on last page)

DISPUTED

AMOUNT OF CLAIM WITHOUT DEDUCTING VALUE OF COLLATERAL

UNSECURED PORTION, IF ANY

$

$

$
(Report also on Summary of Schedules.)

$
(If applicable, report also on Statistical Summary of Certain Liabilities and Related Data.)

B6E (Official Form 6E) (12/07) In re Debtor , Case No. (if known)

SCHEDULE E - CREDITORS HOLDING UNSECURED PRIORITY CLAIMS
A complete list of claims entitled to priority, listed separately by type of priority, is to be set forth on the sheets provided. Only holders of unsecured claims entitled to priority should be listed in this schedule. In the boxes provided on the attached sheets, state the name, mailing address, including zip code, and last four digits of the account number, if any, of all entities holding priority claims against the debtor or the property of the debtor, as of the date of the filing of the petition. Use a separate continuation sheet for each type of priority and label each with the type of priority. The complete account number of any account the debtor has with the creditor is useful to the trustee and the creditor and may be provided if the debtor chooses to do so. If a minor child is a creditor, state the child's initials and the name and address of the child's parent or guardian, such as "A.B., a minor child, by John Doe, guardian." Do not disclose the child's name. See, 11 U.S.C. 112 and Fed. R. Bankr. P. 1007(m). If any entity other than a spouse in a joint case may be jointly liable on a claim, place an "X" in the column labeled "Codebtor," include the entity on the appropriate schedule of creditors, and complete Schedule H-Codebtors. If a joint petition is filed, state whether the husband, wife, both of them, or the marital community may be liable on each claim by placing an "H," "W," "J," or "C" in the column labeled "Husband, Wife, Joint, or Community." If the claim is contingent, place an "X" in the column labeled "Contingent." If the claim is unliquidated, place an "X" in the column labeled "Unliquidated." If the claim is disputed, place an "X" in the column labeled "Disputed." (You may need to place an "X" in more than one of these three columns.) Report the total of claims listed on each sheet in the box labeled "Subtotals" on each sheet. Report the total of all claims listed on this Schedule E in the box labeled "Total" on the last sheet of the completed schedule. Report this total also on the Summary of Schedules. Report the total of amounts entitled to priority listed on each sheet in the box labeled "Subtotals" on each sheet. Report the total of all amounts entitled to priority listed on this Schedule E in the box labeled "Totals" on the last sheet of the completed schedule. Individual debtors with primarily consumer debts report this total also on the Statistical Summary of Certain Liabilities and Related Data. Report the total of amounts not entitled to priority listed on each sheet in the box labeled "Subtotals" on each sheet. Report the total of all amounts not entitled to priority listed on this Schedule E in the box labeled "Totals" on the last sheet of the completed schedule. Individual debtors with primarily consumer debts report this total also on the Statistical Summary of Certain Liabilities and Related Data. Check this box if debtor has no creditors holding unsecured priority claims to report on this Schedule E.

TYPES OF PRIORITY CLAIMS (Check the appropriate box(es) below if claims in that category are listed on the attached sheets.)
Domestic Support Obligations Claims for domestic support that are owed to or recoverable by a spouse, former spouse, or child of the debtor, or the parent, legal guardian, or responsible relative of such a child, or a governmental unit to whom such a domestic support claim has been assigned to the extent provided in 11 U.S.C. 507(a)(1). Extensions of credit in an involuntary case Claims arising in the ordinary course of the debtor's business or financial affairs after the commencement of the case but before the earlier of the appointment of a trustee or the order for relief. 11 U.S.C. 507(a)(3). Wages, salaries, and commissions Wages, salaries, and commissions, including vacation, severance, and sick leave pay owing to employees and commissions owing to qualifying independent sales representatives up to $10,950* per person earned within 180 days immediately preceding the filing of the original petition, or the cessation of business, whichever occurred first, to the extent provided in 11 U.S.C. 507(a)(4). Contributions to employee benefit plans Money owed to employee benefit plans for services rendered within 180 days immediately preceding the filing of the original petition, or the cessation of business, whichever occurred first, to the extent provided in 11 U.S.C. 507(a)(5).

B6E (Official Form 6E) (12/07) Cont. In re Debtor , Case No. (if known)

Certain farmers and fishermen Claims of certain farmers and fishermen, up to $5,400* per farmer or fisherman, against the debtor, as provided in 11 U.S.C. 507(a)(6).

Deposits by individuals Claims of individuals up to $2,425* for deposits for the purchase, lease, or rental of property or services for personal, family, or household use, that were not delivered or provided. 11 U.S.C. 507(a)(7).

Taxes and Certain Other Debts Owed to Governmental Units Taxes, customs duties, and penalties owing to federal, state, and local governmental units as set forth in 11 U.S.C. 507(a)(8).

Commitments to Maintain the Capital of an Insured Depository Institution Claims based on commitments to the FDIC, RTC, Director of the Office of Thrift Supervision, Comptroller of the Currency, or Board of Governors of the Federal Reserve System, or their predecessors or successors, to maintain the capital of an insured depository institution. 11 U.S.C. 507 (a)(9).

Claims for Death or Personal Injury While Debtor Was Intoxicated Claims for death or personal injury resulting from the operation of a motor vehicle or vessel while the debtor was intoxicated from using alcohol, a drug, or another substance. 11 U.S.C. 507(a)(10).

* Amounts are subject to adjustment on April 1, 2010, and every three years thereafter with respect to cases commenced on or after the date of adjustment.

____ continuation sheets attached

B6E (Official Form 6E) (12/07) Cont. In re __________________________________________, Debtor Case No. _________________________________ (if known)

SCHEDULE E - CREDITORS HOLDING UNSECURED PRIORITY CLAIMS
(Continuation Sheet) Type of Priority for Claims Listed on This Sheet
HUSBAND, WIFE, JOINT, OR COMMUNITY

CONTINGENT

Account No.

Account No.

Account No.

Account No.

CODEBTOR

Sheet no. ___ of ___ continuation sheets attached to Schedule of Creditors Holding Priority Claims

Subtotals' (Totals of this page) Total' (Use only on last page of the completed Schedule E. Report also on the Summary of Schedules.) Totals' (Use only on last page of the completed Schedule E. If applicable, report also on the Statistical Summary of Certain Liabilities and Related Data.)

DISPUTED

CREDITOR'S NAME, MAILING ADDRESS INCLUDING ZIP CODE, AND ACCOUNT NUMBER (See instructions above.)

DATE CLAIM WAS INCURRED AND CONSIDERATION FOR CLAIM

UNLIQUIDATED

AMOUNT OF CLAIM

AMOUNT ENTITLED TO PRIORITY

AMOUNT NOT ENTITLED TO PRIORITY, IF ANY

$

$

$

$

$

B6F (Official Form 6F) (12/07) In re __________________________________________, Debtor Case No. _________________________________ (if known)

SCHEDULE F - CREDITORS HOLDING UNSECURED NONPRIORITY CLAIMS
State the name, mailing address, including zip code, and last four digits of any account number, of all entities holding unsecured claims without priority against the debtor or the property of the debtor, as of the date of filing of the petition. The complete account number of any account the debtor has with the creditor is useful to the trustee and the creditor and may be provided if the debtor chooses to do so. If a minor child is a creditor, state the child's initials and the name and address of the child's parent or guardian, such as "A.B., a minor child, by John Doe, guardian." Do not disclose the child's name. See, 11 U.S.C. 112 and Fed. R. Bankr. P. 1007(m). Do not include claims listed in Schedules D and E. If all creditors will not fit on this page, use the continuation sheet provided. If any entity other than a spouse in a joint case may be jointly liable on a claim, place an "X" in the column labeled "Codebtor," include the entity on the appropriate schedule of creditors, and complete Schedule H - Codebtors. If a joint petition is filed, state whether the husband, wife, both of them, or the marital community may be liable on each claim by placing an "H," "W," "J," or "C" in the column labeled "Husband, Wife, Joint, or Community." If the claim is contingent, place an "X" in the column labeled "Contingent." If the claim is unliquidated, place an "X" in the column labeled "Unliquidated." If the claim is disputed, place an "X" in the column labeled "Disputed." (You may need to place an "X" in more than one of these three columns.) Report the total of all claims listed on this schedule in the box labeled "Total" on the last sheet of the completed schedule. Report this total also on the Summary of Schedules and, if the debtor is an individual with primarily consumer debts, report this total also on the Statistical Summary of Certain Liabilities and Related Data..

G Check this box if debtor has no creditors holding unsecured claims to report on this Schedule F.

UNLIQUIDATED

CONTINGENT

CODEBTOR

(See

instructions above.)

ACCOUNT NO.

ACCOUNT NO.

ACCOUNT NO.

ACCOUNT NO.

Subtotal' _____continuation sheets attached Total' (Use only on last page of the completed Schedule F.) (Report also on Summary of Schedules and, if applicable, on the Statistical Summary of Certain Liabilities and Related Data.)

DISPUTED
$ $

CREDITOR'S NAME, MAILING ADDRESS INCLUDING ZIP CODE, AND ACCOUNT NUMBER

HUSBAND, WIFE, JOINT, OR COMMUNITY

DATE CLAIM WAS INCURRED AND CONSIDERATION FOR CLAIM. IF CLAIM IS SUBJECT TO SETOFF, SO STATE.

AMOUNT OF CLAIM

B6F (Official Form 6F) (12/07) - Cont. In re __________________________________________, Debtor Case No. _________________________________ (if known)

SCHEDULE F - CREDITORS HOLDING UNSECURED NONPRIORITY CLAIMS
(Continuation Sheet)

HUSBAND, WIFE, JOINT, OR COMMUNITY

UNLIQUIDATED

CONTINGENT

CODEBTOR

(See

instructions above.)

ACCOUNT NO.

ACCOUNT NO.

ACCOUNT NO.

ACCOUNT NO.

ACCOUNT NO.

Sheet no.___of___ continuation sheets attached to Schedule of Creditors Holding Unsecured Nonpriority Claims

Subtotal'

DISPUTED
$ $

CREDITOR'S NAME, MAILING ADDRESS INCLUDING ZIP CODE, AND ACCOUNT NUMBER

DATE CLAIM WAS INCURRED AND CONSIDERATION FOR CLAIM. IF CLAIM IS SUBJECT TO SETOFF, SO STATE.

AMOUNT OF CLAIM

Total' (Use only on last page of the completed Schedule F.) (Report also on Summary of Schedules and, if applicable on the Statistical Summary of Certain Liabilities and Related Data.)

B6G (Official Form 6G) (12/07) In re Debtor , Case No. (if known)

SCHEDULE G - EXECUTORY CONTRACTS AND UNEXPIRED LEASES
Describe all executory contracts of any nature and all unexpired leases of real or personal property. Include any timeshare interests. State nature of debtor's interest in contract, i.e., "Purchaser," "Agent," etc. State whether debtor is the lessor or lessee of a lease. Provide the names and complete mailing addresses of all other parties to each lease or contract described. If a minor child is a party to one of the leases or contracts, state the child's initials and the name and address of the child's parent or guardian, such as "A.B., a minor child, by John Doe, guardian." Do not disclose the child's name. See, 11 U.S.C. 112 and Fed. R. Bankr. P. 1007(m). Check this box if debtor has no executory contracts or unexpired leases.

NAME AND MAILING ADDRESS, INCLUDING ZIP CODE, OF OTHER PARTIES TO LEASE OR CONTRACT.

DESCRIPTION OF CONTRACT OR LEASE AND NATURE OF DEBTOR'S INTEREST. STATE WHETHER LEASE IS FOR NONRESIDENTIAL REAL PROPERTY. STATE CONTRACT NUMBER OF ANY GOVERNMENT CONTRACT.

B6H (Official Form 6H) (12/07) In re Debtor , Case No. (if known)

SCHEDULE H - CODEBTORS
Provide the information requested concerning any person or entity, other than a spouse in a joint case, that is also liable on any debts listed by the debtor in the schedules of creditors. Include all guarantors and co-signers. 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 eight-year 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, commonwealth, or territory. Include all names used by the nondebtor spouse during the eight years immediately preceding the commencement of this case. If a minor child is a codebtor or a creditor, state the child's initials and the name and address of the child's parent or guardian, such as "A.B., a minor child, by John Doe, guardian." Do not disclose the child's name. See, 11 U.S.C. 112 and Fed. R. Bankr. P. 1007(m). Check this box if debtor has no codebtors. NAME AND ADDRESS OF CODEBTOR NAME AND ADDRESS OF CREDITOR

B6I (Official Form 6I) (12/07) In re Debtor , Case No. (if known)

SCHEDULE I - CURRENT INCOME OF INDIVIDUAL DEBTOR(S)
The column labeled "Spouse" must be completed in all cases filed by joint debtors and by every married debtor, whether or not a joint petition is filed, unless the spouses are separated and a joint petition is not filed. Do not state the name of any minor child. The average monthly income calculated on this form may differ from the current monthly income calculated on From 22A, 22B, or 22C. Debtor's Marital Status: RELATIONSHIP(S): Employment: Occupation Name of Employer How long employed Address of Employer DEBTOR SPOUSE DEPENDENTS OF DEBTOR AND SPOUSE AGE(S):

INCOME: (Estimate of average or projected monthly income at time case filed) 1. Monthly gross wages, salary, and commissions (Prorate if not paid monthly) 2. Estimate monthly overtime 3. SUBTOTAL 4. LESS PAYROLL DEDUCTIONS a. Payroll taxes and social security b. Insurance c. Union dues d. Other (Specify): 5. SUBTOTAL OF PAYROLL DEDUCTIONS 6. TOTAL NET MONTHLY TAKE HOME PAY 7. Regular income from operation of business or profession or farm (Attach detailed statement) 8. Income from real property 9. Interest and dividends 10. Alimony, maintenance or support payments payable to the debtor for the debtor's use or that of dependents listed above 11. Social security or government assistance (Specify): 12. Pension or retirement income 13. Other monthly income (Specify): 14. SUBTOTAL OF LINES 7 THROUGH 13 15. AVERAGE MONTHLY INCOME (Add amounts on lines 6 and 14)

DEBTOR $________________ $________________

SPOUSE $______________ $______________

$_______________ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

$_____________

$ $

$ 16. COMBINED AVERAGE MONTHLY INCOME: (Combine column totals from line 15) (Report also on Summary of Schedules and, if applicable, on Statistical Summary of Certain Liabilities and Related Data) 17. Describe any increase or decrease in income reasonably anticipated to occur within the year following the filing of this document:

B6J (Official Form 6J) (12/07) In re Debtor , Case No. (if known)

SCHEDULE J - CURRENT EXPENDITURES OF INDIVIDUAL DEBTOR(S)
Complete this schedule by estimating the average or projected monthly expenses of the debtor and the debtor's family at time case filed. Prorate any payments made biweekly, quarterly, semi-annually, or annually to show monthly rate. The average monthly expenses calculated on this form may differ from the deductions from income allowed on Form22A or 22C. Check this box if a joint petition is filed and debtor's spouse maintains a separate household. Complete a separate schedule of expenditures labeled "Spouse." 1. Rent or home mortgage payment (include lot rented for mobile home) a. Are real estate taxes included? b. Is property insurance included? 2. Utilities: a. Electricity and heating fuel b. Water and sewer c. Telephone d. Other ___________________________________________________________________ 3. Home maintenance (repairs and upkeep) 4. Food 5. Clothing 6. Laundry and dry cleaning 7. Medical and dental expenses 8. Transportation (not including car payments) 9. Recreation, clubs and entertainment, newspapers, magazines, etc. 10.Charitable contributions 11.Insurance (not deducted from wages or included in home mortgage payments) a. Homeowner's or renter's b. Life c. Health d. Auto e. Other ___________________________________________________________________ 12. Taxes (not deducted from wages or included in home mortgage payments) (Specify) ___________________________________________________________________________ 13. Installment payments: (In chapter 11, 12, and 13 cases, do not list payments to be included in the plan) a. Auto b. Other ______________________________________________________________ c. Other ____________________________________________________________ 14. Alimony, maintenance, and support paid to others 15. Payments for support of additional dependents not living at your home 16. Regular expenses from operation of business, profession, or farm (attach detailed statement) 17. Other __________________________________________________________________________ 18. AVERAGE MONTHLY EXPENSES (Total lines 1-17. Report also on Summary of Schedules and, if applicable, on the Statistical Summary of Certain Liabilities and Related Data.) 19. Describe any increase or decrease in expenditures reasonably anticipated to occur within the year following the filing of this document: ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ 20. STATEMENT OF MONTHLY NET INCOME a. Average monthly income from Line 15 of Schedule I b. Average monthly expenses from Line 18 above c. Monthly net income (a. minus b.) $______________ $______________ $______________ $ ______________ $ ______________ $ ______________ $ ______________ $ ______________ $ ______________ $______________ $ ______________ $ ______________ $ ______________ $ ______________ $ ______________ $ ______________ Yes ________ Yes ________ No ________ No ________ $ ______________ $ ______________ $ ______________ $ ______________ $ ______________ $ ______________ $ ______________ $ ______________ $ ______________ $ ______________ $ ______________ $ ______________ $ _____________

$______________

B7 (Official Form 7) (12/07)

UNITED STATES BANKRUPTCY COURT

______________________________ DISTRICT OF _____________________________

In re:_____ ___________________________________,
Debtor

Case No. ___________________________________
(if known)

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. To indicate payments, transfers and the like to minor children, state the child's initials and the name and address of the child's parent or guardian, such as "A.B., a minor child, by John Doe, guardian." Do not disclose the child's name. See, 11 U.S.C. 112 and Fed. R. Bankr. P. 1007(m). 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 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 full-time or part-time. An individual debtor also may be "in business" for the purpose of this form if the debtor engages in a trade, business, or other activity, other than as an employee, to supplement income from the debtor's primary employment. "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. Income from employment or operation of business
None

State the gross amount of income the debtor has received from employment, trade, or profession, or from operation of the debtor's business, including part-time activities either as an employee or in independent trade or 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

2
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, 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. Payments to creditors Complete a. or b., as appropriate, and c.
None

a. Individual or joint debtor(s) with primarily consumer debts: List all payments on loans, installment purchases of goods or services, and other debts to any creditor made within 90 days immediately preceding the commencement of this case unless the aggregate value of all property that constitutes or is affected by such transfer is less than $600. Indicate with an asterisk (*) any payments that were made to a creditor on account of a domestic support obligation or as part of an alternative repayment schedule under a plan by an approved nonprofit budgeting and credit counseling agency. (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.) NAME AND ADDRESS OF CREDITOR DATES OF PAYMENTS AMOUNT PAID AMOUNT STILL OWING

______________________________________________________________________________________________________
None

G

b. Debtor whose debts are not primarily consumer debts: List each payment or other transfer to any creditor made within 90 days immediately preceding the commencement of the case unless the aggregate value of all property that constitutes or is affected by such transfer is less than $5,475. If the debtor is an individual, indicate with an asterisk (*) any payments that were made to a creditor on account of a domestic support obligation or as part of an alternative repayment schedule under a plan by an approved nonprofit budgeting and credit counseling agency. (Married debtors filing under chapter 12 or chapter 13 must include payments and other 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.) NAME AND ADDRESS OF CREDITOR DATES OF PAYMENTS/ TRANSFERS AMOUNT PAID OR VALUE OF TRANSFERS AMOUNT STILL OWING

________________________________________________________________________________________________

3
None

G

c. All debtors: 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.) NAME AND ADDRESS OF CREDITOR AND RELATIONSHIP TO DEBTOR DATE OF PAYMENT AMOUNT PAID AMOUNT STILL OWING

______________________________________________________________________________________________________

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.) CAPTION OF SUIT AND CASE NUMBER COURT OR AGENCY AND LOCATION STATUS OR DISPOSITION

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.) NAME AND ADDRESS OF PERSON FOR WHOSE BENEFIT PROPERTY WAS SEIZED DESCRIPTION AND VALUE OF PROPERTY

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

_ ______________________________________________________________________________________________________

4
6.
None

Assignments and receiverships

a. 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

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

______________________________________________________________________________________________________

5
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 PAYER IF OTHER THAN DEBTOR AMOUNT OF MONEY OR DESCRIPTION AND VALUE OF PROPERTY

NAME AND ADDRESS OF PAYEE

______________________________________________________________________________________________________ 10. Other transfers
None

a. 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 two years 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.) NAME AND ADDRESS OF TRANSFEREE, RELATIONSHIP TO DEBTOR DATE DESCRIBE PROPERTY TRANSFERRED AND VALUE RECEIVED

______________________________________________________________________________________________________
None

G

b. List all property transferred by the debtor within ten years immediately preceding the commencement of this case to a self-settled trust or similar device of which the debtor is a beneficiary. NAME OF TRUST OR OTHER DEVICE DATE(S) OF TRANSFER(S) AMOUNT OF MONEY OR DESCRIPTION AND VALUE OF PROPERTY OR DEBTOR'S INTEREST IN PROPERTY

______________________________________________________________________________________________________ 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

______________________________________________________________________________________________________

6
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

G

If debtor has moved within three 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

_____________________________________________________________________________

7
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 eight years 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: SITE NAME AND ADDRESS NAME AND ADDRESS OF GOVERNMENTAL UNIT DATE OF NOTICE ENVIRONMENTAL LAW

______________________________________________________________________________________________________
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. SITE NAME AND ADDRESS NAME AND ADDRESS OF GOVERNMENTAL UNIT DATE OF NOTICE ENVIRONMENTAL LAW

_____________________________________________________________________________________________________
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. NAME AND ADDRESS OF GOVERNMENTAL UNIT DOCKET NUMBER STATUS OR DISPOSITION

______________________________________________________________________________________________________ 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, partner in a partnership, sole proprietor, or was self-employed in a trade, profession, or other activity either full- or part-time within six years immediately preceding the commencement of this case, or in

8
which the debtor owned 5 percent or more of the voting or equity securities within 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 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 six years immediately preceding the commencement of this case. LAST FOUR DIGITS OF SOCIAL-SECURITY OR OTHER INDIVIDUAL TAXPAYER-I.D. NO. (ITIN)/ COMPLETE EIN

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. NAME ADDRESS

______________________________________________________________________________________________________ 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 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 self-employed in a trade, profession, or other activity, either full- or part-time. (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 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 two years immediately preceding the filing of this bankruptcy case kept or supervised the keeping of books of account and records of the debtor. NAME AND ADDRESS DATES SERVICES RENDERED

________________________________________________________________________________________________
None

b. List all firms or individuals who within 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. NAME ADDRESS DATES SERVICES RENDERED

_____________________________________________________________________________________________________

9
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. NAME ADDRESS

________________________________________________________________________________________________
None

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

________________________________________________________________________________________________ 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 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. NAME AND ADDRESS NATURE OF INTEREST PERCENTAGE OF INTEREST

______________________________________________________________________________________________________
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

__________________________________________________________________________________________________

10
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. NAME ADDRESS DATE OF WITHDRAWAL

___________________________________________________________________________________________________
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. NAME AND ADDRESS TITLE DATE OF TERMINATION

___________________________________________________________________________________________________ 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 six years immediately preceding the commencement of the case. NAME OF PARENT CORPORATION TAXPAYER-IDENTIFICATION NUMBER (EIN)

_____________________________________________________________________________________________________ 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 six years immediately preceding the commencement of the case. NAME OF PENSION FUND TAXPAYER-IDENTIFICATION NUMBER (EIN)

* * * * * *

11
[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

Date __________________________

Signature_________________________________________ of Joint Debtor (if any)

__________________________________________________________________________________________________________________________

[If completed on behalf of a partnership or corporation] 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 to the best of my knowledge, information and belief.

Date __________________________ __________________________________________________

Signature

_________________________________________________ Print Name and Title

[An individual signing on behalf of a partnership or corporation must indicate position or relationship to debtor.]

____ 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

___________________________________________________________________________________________________
DECLARATION AND SIGNATURE OF NON-ATTORNEY BANKRUPTCY PETITION PREPARER (See 11 U.S.C. 110) I declare under penalty of perjury that: (1) I am a bankruptcy petition preparer as defined in 11 U.S.C. 110; (2) I prepared this document for compensation and have provided the debtor with a copy of this document and the notices and information required under 11 U.S.C. 110(b), 110(h), and 342(b); and, (3) if rules or guidelines have been promulgated pursuant to 11 U.S.C. 110(h) setting a maximum fee for services chargeable by bankruptcy petition preparers, I have given the debtor notice of the maximum amount before preparing any document for filing for a debtor or accepting any fee from the debtor, as required by that section. _____________________________________________________ Printed or Typed Name and Title, if any, of Bankruptcy Petition Preparer _____________________________ Social-Security No. (Required by 11 U.S.C. 110.)

If the bankruptcy petition preparer is not an individual, state the name, title (if any), address, and social-security number of the officer, principal, responsible person, or partner who signs this document. ________________________________ _________________________________ Address

X _____________________________________________________ Signature of Bankruptcy Petition Preparer

____________________ Date

Names and Social-Security numbers of all other individuals who prepared or assisted in preparing this document unless the bankruptcy petition preparer is not an individual: If more than one person prepared this document, attach additional signed sheets conforming to the appropriate Official Form for each person

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.

B21 (Official Form 21) (12/07)

STATEMENT OF SOCIAL-SECURITY NUMBER OR INDIVIDUAL TAXPAYER-IDENTIFICATION NUMBER (ITIN)
[Caption as in Form 16A.]

STATEMENT OF SOCIAL-SECURITY NUMBER(S) (or other Individual Taxpayer-Identification Number(s) (ITIN(s)))

1.Name of Debtor (Last, First, Middle):_______________________________ (Check the appropriate box and, if applicable, provide the required information.)

G Debtor has a Social-Security Number and it is: _ _ _-_ _-_ _ _ _ (If more than one, state all.) G Debtor does not have a Social-Security Number but has an Individual Taxpayer-Identification Number (ITIN), and it is: ___________________. (If more than one, state all.) G Debtor does not have either a Social-Security Number or an Individual Taxpayer-Identification Number (ITIN).
2.Name of Joint Debtor (Last, First, Middle):___________________________ (Check the appropriate box and, if applicable, provide the required information.)

G Joint Debtor has a Social-Security Number and it is: _ _ _-_ _-_ _ _ _ (If more than one, state all.) G Joint Debtor does not have a Social-Security Number but has an Individual Taxpayer-Identification Number (ITIN) and it is: ________________. (If more than one, state all.) G Joint Debtor does not have either a Social-Security Number or an Individual Taxpayer-Identification Number (ITIN).
I declare under penalty of perjury that the foregoing is true and correct. X ______________________________________________ Signature of Debtor Date ______________________________________________ Signature of Joint Debtor Date

X

______________________________________________________________________________ *Joint debtors must provide information for both spouses. Penalty for making a false statement: Fine of up to $250,000 or up to 5 years imprisonment or both. 18 U.S.C. 152 and 3571.