B7 (Official Form 7)(4/10)
UNITED STATES BANKRUPTCY COURT
DISTRICT OF
In re: , Case No.
Debtor (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. Income other than from employment or operation of business
None
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
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 $5,850 * . 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 AMOUNT AMOUNT
PAYMENTS/ PAID OR STILL
TRANSFERS VALUE OF OWING
TRANSFERS
_________________________________ 2
* Amount subject to adjustment on 4/01/13, and every three years thereafter with respect to cases commenced on or
after the date of adjustment. 3
None
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
spouses are separated and a joint petition is not filed.)
NAME AND ADDRESS OF CREDITOR DATE OF AMOUNT AMOUNT
AND RELATIONSHIP TO DEBTOR PAYMENT PAID STILL OWING
______________________________________________________________________________________________________
4 . Suits and administrative proceedings, executions, garnishments and attachmen ts
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 COURT OR AGENCY STATUS OR
AND CASE NUMBER NATURE OF PROCEEDING AND LOCATION DISPOSTION
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 WHOOSE
BENEFIT PROPERTY WAS SEIZED DATE OF
SEIZURE DESCRIPTION
AND VALUE OF
PROPERTY
_______________________________________________________________________________________________________
5. Repossessions, foreclosures and returns
None
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.)
NAME AND ADDRESS
OF CREDITOR OR SELLER DATE OF REPOSSESSION
FORECLOSURE SALE,
TRANSFER OR RETURN DESCRIPTION
AND VALUE
OF PROPERTY
_______________________________________________________________________________________________________ 4
6. Assignments and receiverships
None
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
NAME AND ADDRESS DATE OF ASSIGNMENT
OF ASSIGNEE ASSIGNMENT OR SETTLEMENT
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 ADDRESS
OF CUSTODIAN NAME AND LOCATION
OF COURT
CASE TITLE & NUMBER DATE OF
ORDER DESCRIPTION
AND VALUE OF
PROPERTY
_______________________________________________________________________________________________________
7. Gifts
None
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 RELATIONSHIP DESCRIPTION
OF PERSON TO DEBTOR, DATE AND VALUE
OR ORGANIZATION IF ANY OF GIFT OF GIFT
_______________________________________________________________________________________________________
8. Losses
None
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. Payments related to debt counseling or bankruptcy
None
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.
NAME AND ADDRESS
OF PAYEE DATE OF PAYMENT,
NAME OF PAYOR IF
OTHER THAN DEBTOR AMOUNT OF MONEY OR
DESCRIPTION AND VALUE
OF PROPERTY
______________________________________________________________________________________________________
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
b. List all property transferred by the debtor within ten years immediately proceeding 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 DATE(S) OF AMOUNT OF MONEY OR DESCRIPTION
DEVICE TRANSFER(S) 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 AMOUNT AND
NAME AND ADDRESS DIGITS OF ACCOUNT NUMBER, DATE OF SALE
OF INSTITUTION AND AMOUNT OF FINAL BALANCE OR CLOSING
_______________________________________________________________________________________________________ 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.)
NAME AND ADDRESS OF CREDITOR DATE OF
SETOFF AMOUNT OF
SETOFF
_______________________________________________________________________________________________________
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 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 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 nature 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 8
executive of a corporation, partner in a partnership, sole proprietorship, or was a self-employed in a trade, profession or
activity either full- or part- time within 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 SOCIAL SECURITY BEGINNING AND
NAME OR OTHER INDIVIDUAL ADDRESS NATURE OF BUSINESS ENDING DATES
TAXPAYER-I.D. NO.
(ITIN)/ COMPLETE EIN
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 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 proprietorship or self-employed in a trade, profession, or other
activity, either full-time 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 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.Listallbookkeepersandaccountantswhowithinthe twoyears immediatelyprecedingthe
filingofthisbankruptcycasekeptorsupervisedthekeepingofbooksofaccountand
recordsofthedebtor.
NAME AND ADDRESS DATE SERVICES RENDERED
_______________________________________________________________________________________________________
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.
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 within the 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.
DATE OF INVENTORY INVENTORY SUPERVISOR DOLLAR AMOUNT OF INVENTORY
(Specify cost, market or other basis)
None
b. List the name and address of the person having possession of the records of each of the inventories reported
in a., above.
DATE OF INVENTORY NAME AND ADDRESS OF CUSTODIAN OF
INVENTORY RECORDS
_______________________________________________________________________________________________________
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.
NAME AND ADDRESS TITLE NATURE AND PERCENTAGE 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 AND ADDRESS
OF RECIPIENT,
RELATIONSHIP TO DEBTOR DATE AND PURPOSE
OF WITHDRAWAL AMOUNT OF MONEY
OR DESCRIPTION
AND VALUE OF PROPERTY
_______________________________________________________________________________________________________
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 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(c).)
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
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 II and the Federal Rules of Bankruptcy Procedure may result
in fines or imprisonment or both. 18 U.S.C. § 156. 12
