Fill and Sign the Statement of Financial Affairs for Individuals Filing for Form

B 7 (Official Form 7) (4/13) 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 pe tition 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 furni sh 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, fa mily farmer, or self-employed professional, should provide the information requested on this statement con cerning 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 o f the child's parent or guardian, such as "A.B., a minor child, by J ohn 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 na me, 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 pur pose of this form if the debtor is or has been, within six years immediately prec eding the filing of this bankruptcy case, any of the following: an officer, director, managi ng 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: relativ es 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 p ersons in control of a corporate debtor and their relatives; affiliates of the debtor and insiders of such affiliates; and any managing a gent of the debtor. 11 U.S.C. § 101(2), (31). ____________________________________________________________________________________________________ 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 th at maintains, or has maintained, financial records on the basis of a fiscal rather than a calendar year may repor t fiscal year income. Identify the beginning and ending dates of the debtor's fiscal year.) If a joint petition is filed, st ate 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 thespouses are separated and a joint petition is not filed.) AMOUNT SOURCE 2 B 7 ( 4/13) * Amount subject to adjustment on 4/01/1 6, and every three years thereafter with respect to cases commenced on or after the date of adjustment. 2. Income other than from employ ment 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 fo r each spouse separately. (Married debtors filing under chapter 12 or chapter 13 must state income for each spouse whether or not a joint pe tition 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 G 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 cons titutes or is affected by such transfer is less than $600. Indicate with an asterisk (*) any payments that were ma de 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 chap ter 13 must include payments by either or both spouses whether or not a joint petition is filed, unless the s pouses are separated and a joint petition is not filed.) NAME AND ADDRESS OF CREDITOR DATES OF AMOUNT AMOUNT PAYMENTS PAID STILL OWING NoneG 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 cas e unless the aggregate value of all property that constitutes or is affected by such transfer is less than $ 6,255* . 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 budge ting 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 OWINGTRANSFERS 3 B 7 ( 4/13) 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 inside rs. (Married debtors filing under chapter 12 or chapter 13 must include payments by either or both spous es 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 AMOUNT AMOUNT AND RELATIONSHIP TO DEBTOR PAYMENT PAID 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 NATURE OF COURT OR AGENCY STATUS OR AND CASE NUMBER PROCEEDING AND LOCATION DISPOSITION None b. Describe all property that has been attached, garnis hed 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 DATE OF DESCRIPTION OF PERSON FOR WHOSE SEIZURE AND VALUE BENEFIT PROPERTY WAS SEIZED 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 th e spouses are separated and a joint petition is not filed.) NAME AND ADDRESS DATE OF REPOSSESSION, DESCRIPTION OF CREDITOR OR SELLER FORECLOSURE SALE, AND VALUE TRANSFER OR RETURN OF PROPERTY ____________________________________________________________________________________________________ 4 B 7 ( 4/13) 6. Assignments and receiverships None a. Describe any assignment of property fo r 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.) NAME AND ADDRESS DATE OF TERMS OF OF ASSIGNEE ASSIGNMENT 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 s pouses whether or not a joint petition is filed, unless the spouses are separated and a joint petition is not filed.) NAME AND ADDRESS NAME AND LOCATION DATE OF DESCRIPTION OF CUSTODIAN OF COURT ORDER AND VALUE CASE TITLE & NUMBER 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 aggreg ating 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 DATE DESCRIPTION OF PERSON TO DEBTOR, OF GIFT AND VALUE OR ORGANIZATION IF ANY 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 jo int petition is filed, unless the spouses are separated and a joint petition is not filed.) DESCRIPTION DESCRIPTION OF CIRCUMSTANCES AND, IF DATE AND VALUE OF LOSS WAS COVERED IN WHOLE OR IN PART OF LOSS PROPERTY BY INSURANCE, GIVE PARTICULARS ____________________________________________________________________________________________________ 5 B 7 ( 4/13) 9. Payments related to debt counseling or bankruptcy None List all payments made or property transferred by or on be half of the debtor to any persons, including attorneys, for consultation concerning debt consolida tion, 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 DATE OF PAYMENT, AMOUNT OF MONEY OR OF PAYEE NAME OF PAYER IF DESCRIPTION AND OTHER THAN DEBTOR VAL UE 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 abso lutely or as security within two years immediately preceding the commencement of this case. (Married debtors filing under chapter 12 or ch apter 13 must include transfers by either or both spouses whether or not a joint petition is filed, unless the s pouses are separated and a joint petition is not filed.) NAME AND ADDRESS DATE DESCRIBE PROPERTYOF TRANSFEREE, TRANSFERRED AND RELATIONSHIP TO DEBTOR 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 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 in struments held in the name of the debtor or for the benefit of the debtor which were closed, sold, or otherw ise 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 whethe r or not a joint petition is filed, unless the spouses are separated and a joint petition is not filed.) NAME AND ADDRESS TYPE OF ACCOUNT, LAST FOUR AMOUNT AND OF INSTITUTION DIGITS OF ACCOUNT NUMBER, DATE OF SALE AND AMOUNT OF FINAL BALANCE OR CLOSING ____________________________________________________________________________________________________ 6 B 7 ( 4/13) 12. Safe deposit boxes None List each safe deposit or other box or depository in which th e 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 NAMES AND ADDRESSES DESCRIPTION DATE OF TRANSFER OF BANK OR OF THOSE WITH ACCESS OF OR SURRENDER, OTHER DEPOSITORY TO BOX OR DEPOSITORY CONTENTS 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 cas e. (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 jointpetition is not filed.) NAME AND ADDRESS DATE OF AMOUNT OF CREDITOR SETOFF OF SETOFF ____________________________________________________________________________________________________ 14. Property held for another person None List all property owned by another pers on that the debtor holds or controls. NAME AND ADDRESS DESCRIPTION AND LOCATION OF PROPERTY OF OWNER VALUE 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 prio r 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 B 7 ( 4/13) 16. Spouses and Former Spouses None If the debtor resides or resided in a community property st ate, commonwealth, or territory (including Alaska, Arizona, California, Idaho, Louisiana, Neva da, 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 toxi c substances, wastes or material into the air, land, soil, surface water, groundwater, or other medium, including, but not limited to, statutes or regul ations 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, in cluding, 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 NAME AND ADDRESS DATE OF ENVIRONMENTAL AND ADDRESS OF GOVERNMENT AL UNIT NOTICE LAW None b. List the name and address of every site for which th e 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 DATE OF ENVIRONMENTAL AND ADDRESS OF GOVERNMENT AL UNIT NOTICE LAW None c. List all judicial or administrative proceedings, in cluding settlements or orders, under any Environmental Law with respect to which the debtor is or was a party. Indicate the na me and address of the governmental unit that is or was a party to the proceeding, and the docket number. NAME AND ADDRESS DOCKET NUMBER STATUS OR OF GOVERNMENTAL UNIT DISPOSITION ____________________________________________________________________________________________________ 18 . Nature, location and name of business None a. If the debtor is an individual , list the names, addresses, taxpayer-identif ication numbers, nature of the businesses, and beginning and ending dates of all busin esses 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 8 B 7 ( 4/13) other 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 six years immediately preceding the commencement of this case. If the debtor is a partnership , list the names, addresses, taxpayer-identifi cation numbers, nature of the businesses, and beginning and ending dates of a ll businesses in which the debtor was a part ner 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-identifi cation numbers, nature of the businesses, and beginning and ending dates of a ll businesses in which the debtor was a part ner or owned 5 percent or more of the voting or equity securities within six years immediately preceding the commencement of this case. NAME LAST FOUR DIGITS ADDRESS NATURE OF BUSINESS BEGINNING AND OF SOCIAL-SECURITY ENDING DATES OR OTHER INDIVIDUAL 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 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-emp loyed in a trade, profession, or other activity, either full- or part-time. (An individual or joint debtor should co mplete this portion of the statement only if the debtor is or has been in business, as defined above, within six years immediately precedi ng the commencement of this case. A debtor who has not been in business within those six years s hould 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 B 7 ( 4/13) 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 th e books of account and records are not available, explain. NAME ADDRESS None d. List all financial institutions, creditors and other pa rties, 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. 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 posse ssion of the records of each of the inventories reported in a., above. DATE OF INVENTORY NAME AND ADDRESSES 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. NATURE AND PERCENTAGE NAME AND ADDRESS TITLE OF STOCK OWNERSHIP __________________________________________________________________________________________________ 10 B 7 ( 4/13) 22 . Former partners, officers, directors and shareholders None a. If the debtor is a partnership, list each memb er 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 dir ectors 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 distribu tions 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 DATE AND PURPOSE AMOUNT OF MONEY OF RECIPIENT, OF WITHDRAWAL OR DESCRIPTION RELATIONSHIP TO DEBTOR AND VALUE OF PROPERTY ___________________________________________________________________ 24. Tax Consolidation Group. None If the debtor is a corporation, list the name and federal ta xpayer-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 TAXP AYER-IDENTIFICATION NUMBER (EIN) ____________________________________________________________________________________ ________________ 25. Pension Funds. None If the debtor is not an individual, list the name and fe deral 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 B 7 ( 4/13) [If completed by an individual or individual and spouse] I declare under penalty of perjury that I have read the answ ers 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 ofJoint 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 a ny 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 cor poration 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 BANK RUPTCY 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 service s 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 o f 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 bankr uptcy 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 Procedur e may result in fines or imprisonment or both. 18 U.S.C. § 156.