Fill and Sign the Debt Bankruptcy Form

IN THE UNITED STATES BANKRUPTCY COURT FOR THE       DISTRICT OF       IN RE: CHAPTER 7 PROCEEDING CASE NO.       PETITIONER VS. ADVERSARY NO. DEBTOR COMPLAINT TO DENY DISCHARGABILITY OF DEBT COMES NOW a Creditor in the above-styled Chapter 7 bankruptcy proceeding, appearing herein by and through its attorney of record, and fles this it's Complaint to Deny Dischargability of Debt and would show unto the Court the following: 1. This Court has jurisdiction pursuant to the provisions of 28 U.S.C. Section 157(a) and (b)(2)(i) and Section 1334 (b) and 11 U.S.C. Section 523. 2. is an business corporation, with its principal place of business in , . 3. is an adult resident citizen of the       Judicial District of County,       who may be served with process at . 4. On or about , , entered into a Brokerage Agreement (hereinafter "Agreement") regarding the ofering and issuance of insurance contracts. is required to remit to all premiums for policies issued. Furthermore, the Agreement provides that credit extended by to an assured shall be at 's sole risk and all premiums shall be paid to when due, whether or not said premiums are collected by . A copy of the Agreement is attached hereto as Exhibit "A" and incorporated herein as reference. 5. Subsequent to execution of the Agreement, issued certain insurance at the request and instruction of . However, has failed or refused to remit to the earned premium related to said policies. As a result, is indebted to for earned premiums related to said insurance contracts pursuant to the Agreement in the amount of $       . has made repeated demand upon for the payment of the debt but has failed or refused to pay said indebtedness. 6. The total sum currently due from for earned premium pursuant to the Agreement entered into by and between and is $ . has made written demand upon for the payment of said sum, but has failed and refused to pay same. is presently indebted to as a result of said breach in the said sum of $ , plus prejudgment interest thereon. 7. Because of the failure and refusal of to pay the amount due , has been forced to hire counsel to fle suit against to recover the amount due . has agreed to pay said counsel a reasonable fee for the services rendered in connection with the collection of the amount due from . is entitled to recover from the unpaid principal amount, plus prejudgment interest thereon, plus reasonable attorney's fees, all costs of court and all other expenses incurred in the litigation of this matter. 8. At all times relevant hereto, Debtor stood in a fduciary and trust relationship with Petitioner with the obligation to forward monies received from insureds to Petitioner and to pay for premiums on policies placed with Petitioner. Debtor breached the fduciary duty by not forwarding monies received from the insureds to Petitioner and instead converted same to his own use. 9. Petitioner would show that Debtor has violated the provisions of 28 U.S.C. Section (2)(A) in that Debtor received services and the extension of credit under false pretenses and fraud. 10. Petitioner would show that Debtor is guilty of fraud while acting in a fduciary capacity in that Debtor converted money to his/her own use although same was rightfully the property of Petitioner in violation of 11 U.S.C. § 523(a)(4). 11. Debtor should be denied a discharge for the Debt to Petitioner based upon the allegations of paragraphs 6 and 7 above so as to allow Petitioner to collect same. 12. Petitioner should also be awarded judgment from Debtor in the amount of $       and all costs and a reasonable attorneys fee. WHEREFORE, PREMISES CONSIDERED, prays that this Honorable Court will fnd this Complaint to Deny Dischargability of Debt to be well taken and will deny the discharge of the debt as to Movant and further award Petitioner judgment against Debtor in the amount of $ plus a reasonable attorneys fee and all costs. DATED, this the day of , . Respectfully submitted, By: ___________________________ OF COUNSEL: CERTIFICATE OF SERVICE I, , do hereby certify that I have this date mailed by United States mail, postage prepaid, a true and correct copy of the above and foregoing document to: DATED, this the day of , 20 . _________________________