Voluntary Petition (United States)
This is the petition for voluntary bankruptcy. The form provided here is simply a sample of what the actual Form B1 looks like.
FORM B1
United States Bankruptcy Court
______________________ District of ___________________________
Voluntary Petition
Name of Debtor (if individual, enter Last, First, Middle):
___________________________
All Other Names used by the Debtor in the last 6 years (include married, maiden, and trade names):
___________________________
Soc. Sec./Tax I.D. No. (if more than one, state all):
Street Address of Debtor (No. & Street, City, State & Zip Code):
___________________________
___________________________
County of Residence or of the Principal Place of Business:
___________________________
Mailing Address of Debtor (if different from street address):
___________________________
___________________________
Name of Joint Debtor (Spouse) (Last, First, Middle):
___________________________
All Other Names used by the Debtor in the last 6 years (include married, maiden, and trade names):
___________________________
Soc. Sec./Tax I.D. No. (if more than one, state all):
___________________________
Street Address of Joint Debtor (No. & Street, City, State & Zip Code):
___________________________
___________________________
County of Residence or of the Principal Place of Business:
___________________________
Mailing Address of Joint Debtor (if different from street address):
___________________________
Location of Principal Assets of Business Debtor (if different from street address above):
___________________________
Information Regarding the Debtor (Check the Applicable Boxes)
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.
Type of Debtor (Check all boxes that apply)
____ Individual(s)
____ Corporation
____ Partnership
____ Railroad
____ Stockbroker
____ Commodity Broker
____ Other ____________________________
Chapter or Section of Bankruptcy Code Under Which the Petition is Filed (Check one box)
____ Chapter 7
____ Chapter 9
____ Chapter 11
____ Chapter 12
____ Chapter 13
____ Sec. 304 - Case ancillary to foreign proceeding
Nature of Debts (Check one box)
____ Consumer/Non-Business
____ Business
Chapter 11 Small Business (Check all boxes that apply)
____ Debtor is a small business as defined in 11 U.S.C. § 101
____ Debtor is and elects to be considered a small business under 11 U.S.C. § 1121(e) (Optional)
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 No. 3.
Statistical/Administrative Information (Estimates only)
____ 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
____ 1-15 ____ 16-49 ____ 50-99 ____ 100-199 ____ 200-999 ____ 1000-over
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
____ More than $100 million
Estimated Debts
____ $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
____ More than $100 million
THIS SPACE IS FOR COURT USE ONLY
Voluntary Petition
(This page must be completed and filed in every case)
Name of Debtor: ___________________________
Prior Bankruptcy Case Filed Within Last 6 Years (If more than one, attach additional sheet)
Location Where Filed: ___________________________
Case Number: ___________________________
Date Filed: ___________________________
Pending Bankruptcy Case Filed by any Spouse, Partner or Affiliate of this Debtor (If more than one, attach additional sheet)
Name of Debtor(s): ___________________________
Case Number: ___________________________
Date Filed: ___________________________
District: ___________________________
Relationship: ___________________________
Judge: ___________________________
Signatures
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.
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)
___________________________
Date
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 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
Signature of Attorney
X ___________________________
Signature of Attorney for Debtor(s)
___________________________
Printed Name of Attorney for Debtor(s)
___________________________
Firm Name
___________________________
Address
___________________________
Signature of Non-Attorney Petition Preparer
I certify that I am a bankruptcy petition preparer as defined in 11 U.S.C. § 110, that I prepared this document for compensation, and that I have provided the debtor with a copy of this document.
___________________________
Printed Name of Bankruptcy Petition Preparer
___________________________
Social Security Number
___________________________
Address
___________________________
Names and Social Security numbers of all other individuals who prepared or assisted in preparing this document:
If more than one person prepared this document, attach additional sheets conforming to the appropriate official form for each person.
X ___________________________
Signature of Bankruptcy Petition Preparer
___________________________
Date
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.
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)
____ Exhibit A is attached and made a part of this petition.
Exhibit B
(To be completed if debtor is an individual whose debts are primarily consumer debts)
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.
X ___________________________
Signature of Attorney for Debtor(s)
___________________________
Date