Bankruptcy Form

Bankruptcy Intake

Step 1 of 5 - Debtor Identification

20%

Debtor’s Name(Required)

First Last

Other Names Used in Last 8 Years?(Required)

Yes

Other Names Used in Last 8 Years

Include any assumed names, trade names, and doing business as names

Employer Identification Number (EIN)(Required)

Principal Place of Business Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Do you have different address from principal?(Required)

Yes

Mailing Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Location of principal assets, if different from principal place of business(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Debtor’s website URL

Type of Debtor(Required)

Corporation (including Limited Liability Company (LLC) and Limited Liability Partnership (LLP))

Partnership (excluding LLP)

Other

Describe Debtor’s Business (A)(Required)

Check one:

Health Care Business (as defined in 11 U.S.C. § 101(27A))

Single Asset Real Estate (as defined in 11 U.S.C. § 101(51B))

Railroad (as defined in 11 U.S.C. § 101(44))

Stockbroker (as defined in 11 U.S.C. § 101(53A))

Commodity Broker (as defined in 11 U.S.C. § 101(6))

Clearing Bank (as defined in 11 U.S.C. § 781(3))

None of the above

Other

Describe Debtor’s Business (B)(Required)

Check all that apply:

Tax-exempt entity (as described in 26 U.S.C. § 501)

Investment company, including hedge fund or pooled investment vehicle (as defined in 15 U.S.C. § 80a-3)

Investment advisor (as defined in 15 U.S.C. § 80b-2(a)(11))

C. NAICS Code

North American Industry Classification System 4-digit code that best describes debtor. See http://www.uscourts.gov/four-digit-national-association-naics-codes .

Under which chapter of the Bankruptcy Code is the debtor filing?

Chapter 7

Chapter 9

Chapter 11

Chapter 12

Check all that apply:(Required)

Debtor’s aggregate noncontingent liquidated debts (excluding debts owed to insiders or affiliates) are less than $3,424,000 (amount subject to adjustment on 4/01/28 and every 3 years after that).

The debtor is a small business debtor as defined in 11 U.S.C. § 101(51D). If the debtor is a small business debtor, attach the most recent balance sheet, statement of operations, cash-flow statement, and federal income tax return or if all of these documents do not exist, follow the procedure in 11 U.S.C. § 1116(1)(B).

The debtor is a small business debtor as defined in 11 U.S.C. § 101(51D), and it chooses to proceed under Subchapter V of Chapter 11.

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).

The debtor is required to file periodic reports (for example, 10K and 10Q) with the Securities and Exchange Commission according to § 13 or 15(d) of the Securities Exchange Act of 1934. File the Attachment to Voluntary Petition for Non-Individuals Filing for Bankruptcy under Chapter 11 (Official Form 201A) with this form.

The debtor is a shell company as defined in the Securities Exchange Act of 1934 Rule 12b-2.

Were prior bankruptcy cases filed by or against the debtor within the last 8 years?(Required)

Yes

Case Number 1(Required)

District

When (DD/MM/YY)

Case No.

Case Number 2(Required)

District

When (DD/MM/YY)

Case No.

Do you have more than 2 cases?(Required)

Yes

File(Required)

Drop files here or

Max. file size: 1 GB.

Are any bankruptcy cases pending or being filed by a business partner or an affiliate of the debtor?(Required)

Yes

List(Required)

Debtor

Relationship

District

When

Case No. (If Know)

List all cases. If more than 1 attach a separate list.

Debtor

Relationship

Distict

When

Case No. (If know)

Why is the case filed in this district?(Required)

Check all that apply:

Debtor has had its domicile, 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.

A bankruptcy case concerning debtor’s affiliate, general partner, or partnership is pending in this district.

Does the debtor own or have possession of any real property or personal property that needs immediate attention?(Required)

Yes

Why does the property need immediate attention?(Required)

Check all that apply

It poses or is alleged to pose a threat of imminent and identifiable hazard to public health or safety.

It needs to be physically secured or protected from the weather.

It includes perishable goods or assets that could quickly deteriorate or lose value without attention (for example, livestock, seasonal goods, meat, dairy, produce, or securities-related assets or other options).

Other

What is the Hazard?

Where is the property?(Required)

Street Address Address Line 2 City ZIP / Postal Code

Is the property insured?(Required)

Yes

If the property insured, then

Insurance Agency

Contact Name

Phone

Debtor’s estimation of available funds

Funds will be available for distribution to unsecured creditors.

After any administrative expenses are paid, no funds will be available for distribution to unsecured creditors.

Debtor’s estimation of available funds(Required)

1-49

50-99

1,000-5,000

100-199

200-999

1,000-5,000

5,001-10,000

10,001-25,000

25,001-50,000

50,001-100,000

More than 100,000

Estimated assets(Required)

$0-$50,000

$50,001-$100,000

$100,001-$500,000

$500,001-$1 million

$1,000,001-$10 million

$10,000,001-$50 million

$50,000,001-$100 million

$100,000,001-$500 million

$500,000,001-$1 billion

$1,000,000,001-$10 billion

$10,000,000,001-$50 billion

More than $50 billion

Estimated Liabilities(Required)

$0-$50,000

$50,001-$100,000

$100,001-$500,000

$500,001-$1 million

$1,000,001-$10 million

$10,000,001-$50 million

$50,000,001-$100 million

$100,000,001-$500 million

$500,000,001-$1 billion

$1,000,000,001-$10 billion

$10,000,000,001-$50 billion

More than $50 billion

WARNING -- Bankruptcy fraud is a serious crime. Making a false statement in connection with a bankruptcy case can result in fines up to $500,000 or imprisonment for up to 20 years, or both. 18 U.S.C. §§ 152, 1341, 1519, and 3571.

Authorized Representative Signature(Required)

First Name Last Name

Title(Required)

Date(Required)

MM slash DD slash YYYY

Attorney Information(Required)

First Name Last Name

Title(Required)

Date(Required)

MM slash DD slash YYYY

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Phone(Required)

Email(Required)

Bar Number

State

Bankruptcy Intake

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