Certification of Notice to Consumer Debtor(s) (Official Form B201B)

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Official Form 101Voluntary Petition for Individuals Filing for Bankruptcy
page 1Official Form 101
Voluntar y Petition for Individuals Filing for Bankruptcy 12/15
The bankruptcy forms use
you and Debtor 1 to refer to a debtor filing alone. A married couple may file a bankruptcy case together—called a
joint case—and in joint cases, these forms use you to ask for information from both debtors. For example, if a form asks, “Do you own a car,”
the answer would be yes if either debtor owns a car. When information is needed about the spouses separately, the form uses Debtor 1 and
Debtor 2 to distinguish between them. In joint cases, one of the spouses must report information as Debtor 1 and the other as Debtor 2. The
same person must be Debtor 1 in all of the forms.
Be as complete and accurate as possible. If two married people are filing together, both are equally responsible for supplying correct
information. If more space is needed, attach a separate sheet to this form. On the top of any additional pages, write your name and case number
(if known). Answer every question.
Part 1: Identify Yourself
About Debtor 1: About Debtor 2 (Spouse Only in a Joint Case):
1. Your full name
Write the name that is on y our
government-issued picture
identification (for example,
your

driver’s licen
se or
passport).
Bring y

our pictur
e
identification to your meeting
w

ith the trustee. __________________________________________________
First name
__________________________________________________
Middle name
__________________________________________________
Last name
___________________________
Suffix (Sr., Jr., II, III) __________ ________________________________________
First name
__________________________________________________
Middle name
__________________________________________________
Last name
___________________________
Suffix (Sr., Jr., II, III)
2. All other names you
have used in the last 8
years
Include your marr ied or
maiden names.
__________________________________________________
First name
__________________________________________________
Middle name
__________________________________________________
Last name
__________________________________________________
First name
__________________________________________________
Middle name
__________________________________________________
Last name __________
________________________________________
First name
__________________________________________________
Middle name
__________________________________________________
Last name
__________________________________________________
First name
__________________________________________________
Middle name
__________________________________________________
Last name
3. Only the last 4 digits of
your Social Security
number or federal
Individual Taxpayer
Identification number
(ITIN) xxx – xx – ____ ____ ____ ____
OR
9 xx – xx – ____ ____ ____ ____
xxx – xx – ____ ____ ____ ____
OR
9 xx – xx – ____ ____ ____ ____
United States Bankruptc

y Court for the:
__________
District of __________
Case number
( If known ): _________________________ Chapter you are filing under:  Chapter 7  Chapter 11  Chapter 12  Chapter 13
Fill in this information to identify your case:
 Check if this is an
amended filing

Debtor 1 _______________________________________________________ Case number (if known ) _____________________________________ First Name Middle Name Last Name Official Form 101
Voluntary Petition for Individuals Filing for Bankruptcy
page 2
About Debtor 1: About Debtor 2 (Spouse Only in a Joint Case):
4. Any business names
and Employer
Identification Numbers
(EIN) you have used in
the last 8 years
Include trade na mes and doing business a
s names
 I have not used any business names or EINs.
_________________________________________________
Business name
_________________________________________________
Business name
___ ___ – ___ ___ ___ ___ ___ ___ ___
EIN
___ ___ – ___ ___ ___ ___ ___ ___ ___
EIN
 I have not used any business names or EINs.
_________________________________________________
Business name
_________________________________________________
Business name
___ ___ – ___ ___ ___ ___ ___ ___ ___
EIN
___ ___ – ___ ___ ___ ___ ___ ___ ___
EIN
5. Where you live
__________

_______________________________________
Number Street
_________________________________________________
_________________________________________________
City State ZIP Code
_________________________________________________
County
If your mailing address is different from the one
above, fill it in here. Note that the court will send
any notices to you at this mailing address.
_________________________________________________
Number Street
_________________________________________________
P.O. Box
_________________________________________________
City State ZIP Code
If Debtor 2 lives at a different address:
_________________________________________________
Number Street
_________________________________________________
_________________________________________________
City State
ZIP

Code
_________________________________________________
County
If Debtor 2’s mailing address is different from
yours, fill it in here. Note that the court will send
any notices to this mailing address.
_________________________________________________
Number Street
_________________________________________________
P.O. Box
_________________________________________________
City State
ZIP

Code
6. Why you are choosing
this district to file for
bankruptcy Check one:
 Over the last 180 days befor e filing this petition, I have lived in this district longer than in an y
other district.
 I have another re ason. Explain. (See 28 U.S.C. § 1408.)
_______________________________________
_
___________

____________________________
_
___________

____________________________
_
Check one:
 Over the last 180 days befor e filing this petition, I have lived in this district longer than in an y
other district.
 I have another re ason. Explain. (See 28 U.S.C. § 1408.)
_______________________________________
_
___________

____________________________
_
___________

_____________________________

Debtor 1 _______________________________________________________ Case number (if known ) _____________________________________ First Name Middle Name Last Name Official Form 101
Voluntary Petition for Individuals Filing for Bankruptcy
page 3
Part 2: Tell the Court About Your Bankruptcy Case
7. The chapter of the
Bankruptcy Code you
are choosing to file
under Check one. (For a brief description of each, see Notice Required by 11 U.S.C. § 342(b) for Individuals Filing
for Bankruptcy (Form 2010)). Also, go to the top of page 1 and check the appropriate box.
 Chapter 7
 Chapter 11
 Chapter 12
 Chapter 13
8. How you will pay the fee  I will pay the entire fee when I file my petition . Please check with the clerk’s office in your
local court for more details about how you ma y pay. Typically, if you are paying the fee
yourself, you may pay with cash, cashier’s c heck, or money order. If your attorney is
submitting your payment on your behalf, your a ttorney may pay with a credit card or check
with a pre-printed address.
 I need to pay the fee in installments . If you choose this option, sign and attach the
Application for Individuals to Pa y The Filing Fee in Installments (Official Form 103A).
 I request that my fee be waived (You may request this option only if you are filing for Chapter 7.
By law, a judge may, but is not required to, waive your fee, and may do so only if your income is
less than 150% of the official poverty line that appl ies to your family size and you are unable to
pay the fee in installments). If you choose this option, you must fill out the Application to Have the
Chapter 7 Filing Fee Waived (Official Form 103B) and file it with your petition.
9. Have you filed for
bankruptcy within the
last 8 years?  No
 Yes. District __________________________ When _______________ Case number ___________________________
MM / DD / YYYY
District
__________________________ When _______________ Case number ___________________________ MM / DD / YYYY
District __________________________ When _______________ Case number ___________________________
MM / DD / YYYY
10. Are any bankruptcy
cases pending or being
filed by a spouse who is
not filing this case with
you, or by a business
partner, or by an
affiliate?  No
 Yes. Debtor _________________________________________________ Relationship to you _____________________
District __________________________ When _______________ Case number, if known____________________
MM / DD / YYYY
Debtor _________________________________________________ Relationship to you _____________________ District __________________________ When _______________ Case number, if known____________________ MM / DD / YYYY
11. Do you rent your
residence?  No. Go to line 12.
 Yes. Has your landlord obtained an eviction judgment against you and do you want to stay in your
residence?
 No. Go to line 12.
 Yes. Fill out Initial Statement About an Eviction Judgment Against You (Form 101A) and file it wi th
this bankruptc

y petition.

tity
such as a corporation, pa rtnership, or LLC.
If

you have more
than one
sole proprietorship, use a
separate sheet a nd attach it to this petition.
 No. Go to Part 4.
 Yes. Name and location of business
_______________________________________________________________________________________
Name of business, if any
_______________________________________________________________________________________
Number Stree
t
_______________________________________________________________________________________
_______________________________________________ _______ __________________________

City State ZIP Code
Check the appro priate box to describe your business:
 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))
 Stockbroker (as defined in 11 U.S.C. § 101(53A))
 Commodity Broker (as defined in 11 U.S.C. § 101(6))
 None of the a bove
13. Are you filing under
Chapter 11 of the
Bankruptcy Code and
are you a small business
debtor ?
For a definition of sm all business debtor , see 11 U.S.C. § 10

1(51D). If you are filing under Chapter 11, the court must know whether you are a small business debtor so that it
can set appropriate deadlines.
If you indicate that you are a small business debtor, you must attach your
most recent balance sheet, statement of operations, cash-flow statement, and federal income tax return or if
any of these documents do not exist, follow the procedure in 11 U.S.C. § 1116(1)(B).  No. I am not filing under Chapter 11.
 No. I am filing under Chapter 11, but I am NOT a small business debtor according to the definition in the Bankruptc
y Code.
 Yes. I am filing under Chapter 11 and I am a small business debtor according to the definit ion in the Bankruptc
y Code.
Part 4: Report if You Own or Have Any Hazardous Property or Any Property That Needs Immediate Attention
14. Do you own or have any
property that poses or is
alleged to pose a threat
of imminent and
identifiable hazard to
public health or safety?
Or do you own any
property that needs
immediate attention?
For example, do you own
perishable goods, or livestock
that

must be fed,
or a building that needs urge

nt repairs?
 No
 Yes. What is the hazard? ________________________________________________________________________
__________ ______________________________________________________________
If immediate attention is needed, why is it needed? _______________________________________________
________________________________________________________________________
Where is the property? ________________________________________________________________________ Number
Street
__________

______________________________________________________________
________________________________________ _______ ____________________
City State ZIP Code

Debtor 1 _______________________________________________________ Case number (if known ) _____________________________________ First Name Middle Name Last Name Official Form 101
Voluntary Petition for Individuals Filing for Bankruptcy
page 5
Part 5: Explain Your Efforts to Receive a Briefing About Credit Counseling
15. Tell the court whether
you have received a
briefing about credit
counseling.
The law requires that you
receive a briefing about credit
counseling before you file for
bankruptcy. You must
truthfully check one of the
following choices. If you
cannot do so, you are not
eligible to file.
If you file anyway, the court
can dismiss your case, you
will lose whatever filing fee
you paid, and your creditors
can begin collection activities
again.
About Debtor 1: About Debtor 2 (Spouse Only in a Joint Case):
You must check one:
 I received a briefing from an approved credit
counseling agency within the 180 days before I
filed this bankruptcy petition, and I receive
d a certifica

te of completion
.
Attach a copy of the certificate and the pa yment plan, if an y, that you developed with the agency.
 I received a briefing from an approved creditcounseling agency within the 180 days before I
filed this bankruptcy petition, but I do not have
a certifica

te of completion
.
Within 14 days after you file this bankruptcy petitio n, you MUS T file a copy of the certificate and paymen t plan, if an

y.
 I certify that I asked for credit counselin g services from an approved agency, but w as una

ble to obtain those services during th
e 7 da

ys after I made my request, and exigent
circumstances merit a 30-day temporary waiver
of the requirem
ent.
To ask for a 30

-day temporary waiv
er of the requirement,

attach a separate sh
eet explaining w

hat efforts you made to obtain the briefing, wh
y you

were unable to obtain it before y
ou filed for bankruptc

y, and what exigent
circumstances required

you to file this case.
Your case may be dismissed
if the court is dissatisf ied with your reasons for not receiving a briefing before

you filed for bankruptcy.
If the court is satisfied with your reasons, y
ou must still r

eceive a briefing within 30 days after y
ou file. Y

ou must file a certificate from th
e approved agenc

y, along with a copy of the payment plan
you developed, if an

y. If you do not do so, y
our case ma

y
be dismissed.
An

y extension of the 30-day dea
dline is granted onl

y for cause and is lim
ited to a maximum of 15 da

ys
.
 I am not required to receive a briefing abou t credit c ounseling because of:
 Incapacity. I have a mental illness or a mentaldeficiency
that makes me
incapable of realizing or making
rational decisions about finances.
 Disability. My physical disability causes me to be unable to p
articipate in a
briefing in person, by phone, or
through the internet, even after I
reasonably tried to do so.
 Active duty. I am currently on active military dut
y in a military combat zone.
If you believe you are not required to receive a
briefing about credit counseling, you must file a
motion for waiver of credit counseling with the court. You must check one:
 I received a briefing from an approved credit
counseling agency within the 180 days before I
filed this bankruptcy petition, and I receive
d a certifica

te of completion
.
Within 14 days after you file this bankruptcy petitio n, you MUS T file a copy of the certificate and paymen t plan, if an

y.
 I certify that I asked for credit counselin g services from an approved agency, but w as una

ble to obtain those services during th
e 7 da

ys after I made my request, and exigent
circumstances merit a 30-day temporary waiver
of the requirem
ent.
To ask for a 30

-day temporary waiv
er of the requirement,

attach a separate sh
eet explaining w

hat efforts you made to obtain the briefing, wh
y you

were unable to obtain it before y
ou filed for bankruptc

y, and what exigent
circumstances required

you to file this case.
Your case may be dismissed
if the court is dissatisf

ied with your reasons for
not receiving a briefing before

you filed for bankruptcy.
If the court is satisfied with your reasons, yo
u must still r

eceive a briefing within 30 days after y
ou file. Y

ou must file a certificate from th
e approved agenc

y, along with a copy of the payment plan
you developed, if an

y. If you do not do so, y
our case ma

y
be dismissed.
An

y extension of the 30-day dea
dline is granted onl

y for cause and is lim
ited to a maximum of 15 da

ys
.
 I am not required to receive a briefing abou t credit c ounseling because of:
 Incapacity. I have a mental illness or a mentaldeficiency
that makes me
incapable of realizing or making
rational decisions about finances.
 Disability. My physical disability causes me to be unable to p
articipate in a
briefing in person, by phone, or
through the internet, even after I
reasonably tried to do so.
 Active duty. I am currently on active military duty
in a military combat zone.
If you believe you are not required to receive a
briefing about credit counseling, you must file a
motion for waiver of credit counseling with the court.

Debtor 1 _______________________________________________________ Case number (if known ) _____________________________________ First Name Middle Name Last Name Official Form 101
Voluntary Petition for Individuals Filing for Bankruptcy
page 6
Part 6: Answer These Questions for Reporting Purposes
16. What kind of debts do
you have? 16a. Are your debts primarily consumer debts? Consumer debts are defined in 11 U.S.C. § 101(8)
as “incurred by an individual primarily for a personal, family, or household purpose.”
 No. Go to line 16b.
 Yes. Go to line 17 .
16b. Are your debts primarily business debts? Business debts are debts that you incurred to obtain
money for a business or investment or through the operation of the business or investment.
 No. Go to line 16c.
 Yes. Go to line 17 .
16c. State the type of debts you owe that are not consumer debts or business debts.
_______________________________________________________________
17. Are you filing under
Chapter 7?
Do you estimate that after
any exempt property is
excluded and
administrative expenses
are paid that funds will be
available for distribution
to unsecured creditors?  No. I am not filing under Chapter 7. Go to line 18.
 Yes. I am filing under Chapter 7. Do you estimate that after any exempt propert y is excluded and administrative ex penses are paid that funds will be available to distribute to unsecured creditors?
 No
 Yes
18. How many creditors do
you estimate that you
owe?  1-49
 50-99
 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
19. How much do you
estimate your assets to
be worth?  $0-$50,000
 $50,001-$100,00 0
 $100,001-$500,0 00
 $500,001-$1 milli on
 $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
20. How much do you
estimate your liabilities
to be?  $0-$50,000
 $50,001-$100,00 0
 $100,001-$500,0 00
 $500,001-$1 milli on
 $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
Part 7: Sign Below
For you I have examined this petition, and I declare under penalty of perjury that the information provided is true and
correct.
If I have chosen to file under Chapter 7, I am aware that I may proceed, if eligible, under Chapter 7, 11,12, or 13
of title 11, United States Code. I understand the relief available under each chapt er, and I choose to proceed
under Chapter 7.
If no attorney represents me and I did not pay or agree to pay someone who is not an attorney to help me fill out
this document, I have obtained and read the notice required by 11 U.S.C. § 342(b).
I request relief in accordance with the chapter of title 11, United States Code, specified in this petition.
I understand making a false statement, concealing property, or obtaining money or property by fraud in connection
with a bankruptcy case can result in fines up to $250,000, or imprisonment for up to 20 years, or both.
18 U.S.C. §§ 152, 1341, 1519, and 3571.
 ______________________________________________  _____________________________
Signature of Debtor 1
Signature of Debtor 2
Executed on _________________ Executed on __________________
MM / DD / YYYY MM / DD / YYYY

Debtor 1 _______________________________________________________ Case number (if known ) _____________________________________ First Name Middle Name Last Name Official Form 101
Voluntary Petition for Individuals Filing for Bankruptcy
page 8
For you if you are filing this
bankruptcy without an
attorney
If you are represented by
an attorney, you do not
need to file this page. The law allows you, as an individual, to
represent yourself in bankruptcy court, but you
should understand that many people find it extremely difficult to represent
themselves successfully. Becau se bankruptcy has long-term financial and legal
consequences, you are strongly urged to hire a qualified attorney.
To be successful, you must correctly file and handl e your bankruptcy case. The rules are very
technical, and a mistake or inaction may affect your rights. For example, your case may be
dismissed because you did not file a required do cument, pay a fee on time, attend a meeting or
hearing, or cooperate with the court, case trustee, U.S. trustee, bankruptcy administrator, or audit
firm if your case is selected for audit. If that happens, you could lose your right to file another
case, or you may lose protections, includ ing the benefit of the automatic stay.
You must list all your property and debts in the sc hedules that you are required to file with the
court. Even if you plan to pay a particular debt out side of your bankruptcy, you must list that debt
in your schedules. If you do not list a debt, the debt may not be discharged. If you do not list
property or properly claim it as exempt, you may not be able to keep the property. The judge can
also deny you a discharge of all your debts if you do something dishonest in your bankruptcy
case, such as destroying or hiding property, falsif ying records, or lying. Individual bankruptcy
cases are randomly audited to determine if debt ors have been accurate, truthful, and complete.
Bankruptcy fraud is a serious crime; you could be fined and imprisoned.
If you decide to file without an attorney, the court expects you to follow the rules as if you had
hired an attorney. The court will not treat you differently because you are filing for yourself. To be
successful, you must be familiar with the United States Bankruptcy Code, the Federal Rules of
Bankruptcy Procedure, and the local rules of the cour t in which your case is filed. You must also
be familiar with any state exemption laws that apply.
Are you aware that filing for bankruptcy is a serious action with long-term financial and legal
consequences?
 No
 Yes
Are you aware that bankruptcy fraud is a serious crime and that if your bankruptcy forms are
inaccurate or incomplete, you could be fined or imprisoned?
 No
 Yes
Did you pay or agree to pay someone who is not an attorney to help you fill out your bankruptcy forms?
 No
 Yes. Name of Person _____________________________________________________________________. Attach Bankruptcy Petition Preparer’s Notice, Declaration, and Signature (Official Form 119).
By signing here, I acknowledge that I understand the risks involved in filing without an attorney. I
have read and understood this notice, and I am awar e that filing a bankruptcy case without an
attorney may cause me to lose my rights or property if I do not properly handle the case.
 _______________________________________________  ______________________________
Signature of Debtor 1 Signature of Debtor 2
Date _________________ Date _________________
MM / DD / YYYY MM / DD / YYYY
Contact phone ______________________________________ Contact phone ________________________________
Cell phone ______________________________________ Cell phone ________________________________ Email address ______________________________________ Email address ________________________________

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Certification of Notice to Consumer Debtor(s) (Official Form B201B)

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