David j Pokrivnak - Chapter 7 Bankruptcy

8/17/2019 David j Pokrivnak - Chapter 7 Bankruptcy

1/43

B1 (Official Form 1) (4/10)

Pokrivnak, David, J.

Name of Debtor (if individual, enter Last, First, Middle): Name of Joint Debtor (Spouse) (Last, First, Middle):

Voluntary Petition

Northern District of Ohio

United States Bankruptcy Court

All Other Names used by the Joint Debtor in the last 8 yearsAll Other Names used by the Debtor in the last 8 years(include married, maiden, and trade names): (include married, maiden, and trade names):

Last four digits of Soc. Sec. or Individual-Taxpayer I.D. (ITIN)/Complete EIN(if morethan one, state all): 0718

Last four digits of Soc. Sec. or Individual-Taxpayer I.D. (ITIN)/Complete EIN(if morethan one, state all):

Street Address of Debtor (No. & Street, City, and State):

262 E. Western Reserve RoadPoland, OH

Street Address of Joint Debtor (No. & Street, City, and State):

ZIP CODE ZIP CODE44514

County of Residence or of the Principal Place of Business: County of Residence or of the Principal Place of Business:Mahoning

Mailing Address of Joint Debtor (if different from street address):Mailing Address of Debtor (if different from street address):

ZIP CODE ZIP CODE

Location of Principal Assets of Business Debtor (if different from street address above):

ZIP CODE

Chapter 13

Chapter 12

Chapter 9

Chapter 11

Chapter 7

Chapter 15 Petition forRecognition of a Foreign Nonmain Proceeding

Chapter 15 Petition for Recognition of a Foreign

Main Proceeding

Chapter of Bankruptcy Code Under Which

the Petition is Filed (Check one box)

Nature of Business

(Check one box)

Other

Health Care Business

Single Asset Real Estate as defined in

11 U.S.C. § 101(51B)

Clearing Bank

Commodity Broker

Stockbroker

Railroad

Type of Debtor

See Exhibit D on page 2 of this form.

Other (If debtor is not one of the above entities,check this box and state type of entity below.)

_____________________

Partnership

Corporation (includes LLC and LLP)

Individual (includes Joint Debtors)

(Check one box.)(Form of Organization)

Nature of Debts(Check one box)

Tax-Exempt Entity(Check box, if applicable)

Debts are primarily business debts.

Debts are primarily consumer debts, defined in 11 U.S.C.§ 101(8) as “incurred by anindividual primarily for a personal, family, or house-hold purpose.”

Debtor is a tax-exempt organizationunder Title 26 of the United StatesCode (the Internal Revenue Code.)

Filing Fee (Check one box)

Full Filing Fee attached

Filing Fee to be paid in installments (applicable to individuals only). Must attachsigned application for the court's consideration certifying that the debtor is

unable to pay fee except in installments. Rule 1006(b) See Official Form 3A.

Debtor is a small business debtor as defined in 11 U.S.C. § 101(51D).

Debtor is not a small business debtor as defined in 11 U.S.C. § 101(51D).

Check one box:

Check if:

Debtor's aggregate noncontingent liquidated debts (excluding debts owed toinsiders or affiliates) are less than $2,343,300 ( amount subject to adjustment on4/01/13 and every three years thereafter ).Filing Fee waiver requested (applicable to chapter 7 individuals only). Must

attach signed application for the court's consideration. See Official Form 3B.

Chapter 11 Debtors

Check all applicable boxes

A plan is being filed with this petition

Acceptances of the plan were solicited prepetition from one or more classesof creditors, in accordance with 11 U.S.C. § 1126(b).

Statistical/Administrative Information

Debtor estimates that funds will be available for distribution to unsecured creditors.

Debtor estimates that, after any exempt property is excluded and administrative

THIS SPACE IS FOR

COURT USE ONLY

expenses paid, there will be no funds available for distribution to unsecured creditors.

$50,001 to$100,000

$0 to$50,000

$100,001 to$500,000

$500,001 to$1million

$1,000,001to $10million

$10,000,001to $50million

$50,000,001to $100million

$100,000,001to $500million

$500,000,001to $1 billion

More than$1 billion

Estimated Liabilities

$50,001 to$100,000

$50,000,001to $100million

$100,000,001to $500million

$0 to$50,000

Estimated Assets

Over 100,000

50,001-100,000

25,001-50,000

10,001-25,000

5,001-10,000

1,000-5,000

200-999

100-199

50-99

1-49

$100,001 to$500,000

$1,000,001to $10million

$500,001 to$1million

$10,000,001to $50million

$500,000,001to $1 billion

More than$1 billion

Estimated Number of Creditors

12-42855-kw Doc 1 FILED 11/20/12 ENTERED 11/20/12 14:06:50 Page 1 of 43


2/43

FORM B1, PageB1 (Official Form 1) (4/10)

Voluntary Petition Name of Debtor(s):(This page must be completed and filed in every case)

David J. Pokrivnak

NONE

All Prior Bankruptcy Cases Filed Within Last 8 Years (If more than two, attach additional sheet.)

Case Number: Date Filed:LocationWhere Filed:

Location

Where Filed:Case Number: Date Filed:

NONE

Pending Bankruptcy Case Filed by any Spouse, Partner or Affiliate of this Debtor (If more than one, attach additional sheet)

Judge:

Name of Debtor: Case Number: Date Filed:

Relationship:District:

Exhibit A

Exhibit A is attached and made a part of this petition.

(To be completed if debtor is required to file periodic reports (e.g., forms 10K and10Q) 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.)

/s/tgeorge

have informed the petitioner that [he or she] may proceed under chapter 7, 11,

I, the attorney for the petitioner named in the foregoing petition, declare that I

whose debts are primarily consumer debts)(To be completed if debtor is an individual

Exhibit B

11/20/2012

available under each such chapter. I further certify that I have delivered to the12, or 13 of title 11, United States Code, and have explained the relief

X

debtor the notice required by 11 U.S.C. § 342(b).

DateSignature of Attorney for Debtor(s)

Timothy F. George 0037254

Yes, and Exhibit C is attached and made a part of this petition.

No

Does the debtor own or have possession of any property that poses or is alleged to pose a threat of imminent and identifiable harm to public health or safety?

Exhibit C

Exhibit D

(To be completed by every individual debtor. If a joint petition is filed, each spouse must complete and attach a separate Exhibit D.)

Exhibit D completed and signed by the debtor is attached and made a part of this petition.

If this is a joint petition:

Exhibit D also completed and signed by the joint debtor is attached and made a part of this petition.

Landlord has a judgment against the debtor for possession of debtor's residence. (If box checked, complete the following).

Certification by a Debtor Who Resides as a Tenant of Residential Property

(Check all applicable boxes.)

Debtor is a debtor in a foreign proceeding and has its principal place of business or principal assets in the United States in this District. orhas no principal place of business or assets in the United States but is a defendant in an action or proceeding [in a federal or state court] inthis District, or the interests of the parties will be served in regard to the relief sought in this District.

There is a bankruptcy case concerning debtor's affiliate. general partner, or partnership pending in this District.

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.

(Check any applicable box)Information Regarding the Debtor - Venue

(Name of landlord that obtained judgment)

Debtor has included in this petition the deposit with the court of any rent that would become due during the 30-day period after thefiling of the petition.

Debtor claims that under applicable nonbankruptcy law, there are circumstances under which the debtor would be permitted to cure theentire monetary default that gave rise to the judgment for possession, after the judgment for possession was entered, and

(Address of landlord)

Debtor certifies that he/she has served the Landlord with this certification. (11 U.S.C. § 362(l)).



3/43

FORM B1, PageB1 (Official Form 1) (4/10)

Voluntary Petition Name of Debtor(s):

David J. Pokrivnak (This page must be completed and filed in every case)

X Not Applicable

Pursuant to 11 U.S.C. § 1511, I request relief in accordance with theChapter of title 11 specified in the petition. A certified copy of theorder granting recognition of the foreign main proceeding is attached.

(Check only one box.)

I request relief in accordance with chapter 15 of Title 11, United States Code.Certified Copies of the documents required by § 1515 of title 11 are attached.[If no attorney represents me and no bankruptcy petition preparer signs the petition] I

have obtained and read the notice required by 11 U.S.C. § 342(b).

s/ David J. Pokrivnak X

I request relief in accordance with the chapter of title 11, United States Code, specifiedin this petition.

[If petitioner is an individual whose debts are primarily consumer debts and haschosen to file under chapter 7] I am aware that I may proceed under chapter 7, 11, 12or 13 of title 11, United States Code, understand the relief available under each suchchapter, and choose to proceed under chapter 7.

I declare under penalty of perjury that the information provided in this petition is trueand correct.

Signature(s) of Debtor(s) (Individual/Joint)

Signatures

Signature of a Foreign Representative

I declare under penalty of perjury that the information provided in this petition is trueand correct, that I am the foreign representative of a debtor in a foreign proceeding,and that I am authorized to file this petition.

Not ApplicableX

Signature of Debtor (Signature of Foreign Representative)David J. Pokrivnak

Signature of Joint Debtor (Printed Name of Foreign Representative)

Telephone Number (If not represented by attorney)

Date

Date11/20/2012

Atty. Tim George & Assoc. Co., L.P.A.

1029 Youngstown Warren Road Niles, Ohio 44446

Timothy F. George Bar No. 0037254

I declare under penalty of perjury that: (1) I am a bankruptcy petition preparer as definedin 11 U.S.C. § 110; (2) I prepared this document for compensation and have providedthe debtor with a copy of this document and the notices and information required under11 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 serviceschargeable by bankruptcy petition preparers, I have given the debtor notice of themaximum amount before preparing any document for filing for a debtor or accepting anyfee from the debtor, as required in that section. Official Form 19 is attached.

Signature of Non-Attorney Petition Preparer

Firm Name

Printed Name of Attorney for Debtor(s) / Bar No.

Signature of Attorney for Debtor(s)

X

Signature of Attorney

/s/tgeorge

330-652-8053330-652-8000

11/20/2012

Telephone Number

Printed Name and title, if any, of Bankruptcy Petition Preparer

Address Not Applicable

Social-Security number (If the bankruptcy petition preparer is not an individual,state the Social-Security number of the officer, principal, responsible person or partner of the bankruptcy petition preparer.) (Required by 11 U.S.C. § 110.)

*In a case in which § 707(b)(4)(D) applies, this signature also constitutes acertification that the attorney has no knowledge after an inquiry that theinformation in the schedules is incorrect.

Date

Address

I declare under penalty of perjury that the information provided in this petition is trueand correct, and that I have been authorized to file this petition on behalf of thedebtor.

Signature of Debtor (Corporation/Partnership)Not ApplicableX

If more than one person prepared this document, attach to the appropriate officialform for each person.

Not Applicable

The debtor requests the relief in accordance with the chapter of title 11, United StatesCode, specified in this petition.

XSignature of Authorized Individual

Printed Name of Authorized Individual

Title of Authorized Individual

Date

Names and Social-Security numbers of all other individuals who prepared orassisted in preparing this document unless the bankruptcy petition preparer is not anindividual.

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.

Date

Signature of bankruptcy petition preparer or officer, principal, responsible person, or partner whose Social-Security number is provided above.



4/43

B 1D (Official Form 1, Exhibit D) (12/09)

UNITED STATES BANKRUPTCY COURT


David J. PokrivnakIn re Case No.

Debtor (if known)

EXHIBIT D - INDIVIDUAL DEBTOR'S STATEMENT OF COMPLIANCE WITHCREDIT COUNSELING REQUIREMENT

Warning: You must be able to check truthfully one of the five statements regarding credit counselinglisted below. If you cannot do so, you are not eligible to file a bankruptcy case, and the court can dismiss anycase you do file. If that happens, you will lose whatever filing fee you paid, and your creditors will be able toresume collection activities against you. If your case is dismissed and you file another bankruptcy case later,you may be required to pay a second filing fee and you may have to take extra steps to stop creditors'collection activities.

Every individual debtor must file this Exhibit D. If a joint petition is filed, each spouse must complete and filea separate Exhibit D. Check one of the five statements below and attach any documents as directed.

1. Within the 180 days before the filing of my bankruptcy case, I received a briefing from a creditcounseling agency approved by the United States trustee or bankruptcy administrator that outlined the opportunitiesfor available credit counseling and assisted me in performing a related budget analysis, and I have a certificate fromthe agency describing the services provided to me. Attach a copy of the certificate and a copy of any debt repayment

plan developed through the agency.

2. Within the 180 days before the filing of my bankruptcy case, I received a briefing from a creditcounseling agency approved by the United States trustee or bankruptcy administrator that outlined the opportunitiesfor available credit counseling and assisted me in performing a related budget analysis, but I do not have a certificatefrom the agency describing the services provided to me. You must file a copy of a certificate from the agencydescribing the services provided to you and a copy of any debt repayment plan developed through the agency nolater than 14 days after your bankruptcy case is filed.

3. I certify that I requested credit counseling services from an approved agency but was unable toobtain the services during the seven days from the time I made my request, and the following exigent circumstancesmerit a temporary waiver of the credit counseling requirement so I can file my bankruptcy case now. [Summarizeexigent circumstances here.]

If your certification is satisfactory to the court, you must still obtain the credit counseling briefingwithin the first 30 days after you file your bankruptcy petition and promptly file a certificate from the agencythat provided the counseling, together with a copy of any debt management plan developed through theagency. Failure to fulfill these requirements may result in dismissal of your case. Any extension of the 30-daydeadline can be granted only for cause and is limited to a maximum of 15 days. Your case may also be

dismissed if the court is not satisfied with your reasons for filing your bankruptcy case without firstreceiving a credit counseling briefing.



5/43

B 1D (Official Form 1, Exh. D) (12/09) – Cont.

Incapacity. (Defined in 11 U.S.C. § 109(h)(4) as impaired by reason of mental illness or mentaldeficiency so as to be incapable of realizing and making rational decisions with respect to financialresponsibilities.);

4. I am not required to receive a credit counseling briefing because of: [Check the applicablestatement.] [Must be accompanied by a motion for determination by the court.]

Disability. (Defined in 11 U.S.C. § 109(h)(4) as physically impaired to the extent of beingunable, after reasonable effort, to participate in a credit counseling briefing in person, by telephone, orthrough the Internet.);

Active military duty in a military combat zone.

5. The United States trustee or bankruptcy administrator has determined that the credit counselingrequirement of 11 U.S.C. ' 109(h) does not apply in this district.

I certify under penalty of perjury that the information provided above is true and correct.

Signature of Debtor:

David J. Pokrivnak

s/ David J. Pokrivnak

11/20/2012Date:



6/43

B6A (Official Form 6A) (12/07)

,In re: Case No.

(If known)David J. Pokrivnak

Debtor

SCHEDULE A - REAL PROPERTY

DESCRIPTION ANDLOCATION OF

PROPERTY

NATURE OF DEBTOR'SINTEREST IN PROPERTY

AMOUNT OFSECURED

CLAIM

CURRENT VALUE

OF DEBTOR'SINTEREST IN

PROPERTY, WITHOUTDEDUCTING ANYSECURED CLAIM

OR EXEMPTION

H U S B A N D , W I F E , J O I N T

O R C O M M U N I T Y

NONE

Total 0.00

(Report also on Summary of Schedules.)



7/43

B6B (Official Form 6B) (12/07)

,In re Case No.

(If known)

David J. Pokrivnak

Debtor

SCHEDULE B - PERSONAL PROPERTY

TYPE OF PROPERTY

CURRENT VALUE OFDEBTOR'S INTERESTIN PROPERTY, WITH-OUT DEDUCTING ANY

SECURED CLAIMOR EXEMPTION

DESCRIPTION AND LOCATIONOF PROPERTY N

O N E



Cash on hand1. X

Checking, savings or other financialaccounts, certificates of deposit, orshares in banks, savings and loan, thrift,building and loan, and homesteadassociations, or credit unions, brokeragehouses, or cooperatives.

2. X

Security deposits with public utilities,telephone companies, landlords, andothers.

3. X

Household goods and furnishings,including audio, video, and computerequipment.

4. Computer; stereo; television 300.00

Books, pictures and other art objects,antiques, stamp, coin, record, tape,compact disc, and other collections orcollectibles.

5. X

Wearing apparel.6. Clothing 100.00

Furs and jewelry.7. X

Firearms and sports, photographic, andother hobby equipment.

8. X

Interests in insurance policies. Nameinsurance company of each policy anditemize surrender or refund value ofeach.

9. X

Annuities. Itemize and name eachissuer.

10. X

Interests in an education IRA as definedin 26 U.S.C. § 530(b)(1) or under aqualified State tuition plan as defined in26 U.S.C. § 529(b)(1). Give particulars.(File separately the record(s) of any suchinterest(s). 11 U.S.C. § 521(c).)

11. X

Interests in IRA, ERISA, Keogh, or otherpension or profit sharing plans. Giveparticulars.

12. X

Stock and interests in incorporated andunincorporated businesses. Itemize.

13. X

Interests in partnerships or joint ventures.Itemize.

14. X

Government and corporate bonds andother negotiable and nonnegotiableinstruments.

15. X

Accounts receivable.16. X

Alimony, maintenance, support, andproperty settlements to which the debtoris or may be entitled. Give particulars.

17. X

Other liquidated debts owed to debtorincluding tax refunds. Give particulars.

18. X



8/43

B6B (Official Form 6B) (12/07) -- Cont.

,In re Case No.

(If known)

David J. Pokrivnak

Debtor

(Continuation Sheet)SCHEDULE B - PERSONAL PROPERTY

TYPE OF PROPERTY

CURRENT VALUE OFDEBTOR'S INTERESTIN PROPERTY, WITH-OUT DEDUCTING ANY

SECURED CLAIMOR EXEMPTION

DESCRIPTION AND LOCATIONOF PROPERTY N

O N E



Equitable or future interests, life estates,and rights or powers exercisable for thebenefit of the debtor other than thoselisted in Schedule A - Real Property.

19. X

Contingent and noncontingent interestsin estate of a decedent, death benefitplan, life insurance policy, or trust.

20. X

Other contingent and unliquidated claimsof every nature, including tax refunds,counterclaims of the debtor, and rights tosetoff claims. Give estimated value ofeach.

21. X

Patents, copyrights, and other intellectualproperty. Give particulars.

22. X

Licenses, franchises, and other generalintangibles. Give particulars.

23. X

24. XCustomer lists or other compilationscontaining personally identifiableinformation (as defined in 11 U.S.C. §101(41A)) provided to the debtor byindividuals in connection with obtaining aproduct or service from the debtor primarilyfor personal, family, or householdpurposes.

Automobiles, trucks, trailers, and othervehicles and accessories.

25. X

Boats, motors, and accessories.26. X

Aircraft and accessories.27. X

Office equipment, furnishings, andsupplies.

28. X

Machinery, fixtures, equipment andsupplies used in business.

29. X

Inventory.30. X

Animals.31. X

Crops - growing or harvested. Giveparticulars.

32. X

Farming equipment and implements.33.

XFarm supplies, chemicals, and feed.34. X

Other personal property of any kind notalready listed. Itemize.

35. X

Total $ 400.00

(Include amounts from any continuation shattached. Report total also on Summary ofSchedules.)

continuation sheets attached1



9/43

,In re Case No.

Debtor (If known)

David J. Pokrivnak

B6C (Official Form 6C) (4/10)

SCHEDULE C - PROPERTY CLAIMED AS EXEMPT

11 U.S.C. § 522(b)(2)

(Check one box)

Debtor claims the exemptions to which debtor is entitled under:

11 U.S.C. § 522(b)(3)

Check if debtor claims a homestead exemption that exceeds$146,450.*

DESCRIPTION OF PROPERTY

SPECIFY LAWPROVIDING EACH

EXEMPTION

VALUE OFCLAIMED

EXEMPTION

CURRENTVALUE OF PROPERTYWITHOUT DEDUCTING

EXEMPTION

Clothing 100.00R.C. § 2329.66(A)(4)(a) 100.00

Computer; stereo; television 300.00R.C. § 2329.66(A)(4)(a) 300.00

* Amount subject to adjustment on 4/1/13 and every three years thereafter with respect to cases commenced on or after the date of adjustment.



10/43

B6D (Official Form 6D) (12/07)

,Case No.In re

(If known)

David J. Pokrivnak

Debtor

SCHEDULE D - CREDITORS HOLDING SECURED CLAIMS

Check this box if debtor has no creditors holding secured claims to report on this Schedule D.

C O N T I N G E N T

DATE CLAIM WASINCURRED, NATURE

OF LIEN, ANDDESCRIPTION AND

VALUE OF PROPERTYSUBJECT TO LIEN

AMOUNT OFCLAIM WITHOUT

DEDUCTINGVALUE OF

COLLATERAL

UNSECUREPORTION,

ANY

D I S P U T E D

U N L I Q U I D A T E D



CREDITOR'S NAME ANDMAILING ADDRESS

INCLUDING ZIP CODE ANDAN ACCOUNT NUMBER

(See Instructions, Above.) C O D E B T O R

ACCOUNT NO. __________________________ VALUE

NONE

0attachedcontinuation sheets

$$ 0(Total of this page)

Subtotal0.00

$$ 0.(Use only on last page)

Total 0.00

(If applicable, repoalso on StatisticalSummary of CertaLiabilities andRelated Data.)

(Report also on Summary ofSchedules)



11/43

B6E (Official Form 6E) (4/10)

, Case No.In re

Debtor (If known)David J. Pokrivnak

SCHEDULE E - CREDITORS HOLDING UNSECURED PRIORITY CLAIMS

Check this box if debtor has no creditors holding unsecured priority claims to report on this Schedule E.

TYPES OF PRIORITY CLAIMS (Check the appropriate box(es) below if claims in that category are listed on the attached sheets.)

Claims for domestic support that are owed to or recoverable by a spouse, former spouse, or child of the debtor, or the parent, legal guardian, or responsible relative of such a child, or a governmental unit to whom such a domestic support claim has been assigned to the extent provided in11 U.S.C. § 507(a)(1).

Domestic Support Obligations

Extensions of credit in an involuntary case

Claims arising in the ordinary course of the debtor's business or financial affairs after the commencement of the case but before the earlier of theappointment of a trustee or the order for relief. 11 U.S.C. § 507(a)(3).

Wages, salaries, and commissions

Wages, salaries, and commissions, including vacation, severance, and sick leave pay owing to employees and commissions owing to qualifying

independent sales representatives up to $11,725* per person earned within 180 days immediately preceding the filing of the original petition, or thecessation of business, whichever occurred first, to the extent provided in 11 U.S.C. § 507(a)(4).

Money owed to employee benefit plans for services rendered within 180 days immediately preceding the filing of the original petition, or thecessation of business, whichever occurred first, to the extent provided in 11 U.S.C. § 507(a)(5).

Contributions to employee benefit plans

Certain farmers and fishermen

Claims of certain farmers and fishermen, up to $5,775* per farmer or fisherman, against the debtor, as provided in 11 U.S.C. § 507(a)(6).

Claims of individuals up to $2,600* for deposits for the purchase, lease, or rental of property or services for personal, family, or household use,

that were not delivered or provided. 11 U.S.C. § 507(a)(7).

Deposits by individuals

Taxes and Certain Other Debts Owed to Governmental Units

Taxes, customs duties, and penalties owing to federal, state, and local governmental units as set forth in 11 U.S.C. § 507(a)(8).

1 continuation sheets attached

Claims based on commitments to the FDIC, RTC, Director of the Office of Thrift Supervision, Comptroller of the Currency, or Board of Governors of the Federal Reserve System, or their predecessors or successors, to maintain the capital of an insured depository institution. 11 U.S.C.§ 507 (a)(9).

Commitments to Maintain the Capital of an Insured Depository Institution

* Amounts are subject to adjustment on 4/01/13, and every three years thereafter with respect to cases commenced on or after the date ofadjustment.

Claims for death or personal injury resulting from the operation of a motor vehicle or vessel while the debtor was intoxicated from using alcohol, adrug, or another substance. 11 U.S.C. § 507(a)(10).

Claims for Death or Personal Injury While Debtor Was Intoxicated



12/43

B6E (Official Form 6E) (4/10) – Cont.

,In re Case No.

(If known)Debtor

David J. Pokrivnak

SCHEDULE E - CREDITORS HOLDING UNSECURED PRIORITY CLAIMS(Continuation Sheet)

C O D E B T O R



C O N T I N G E N T


D I S P U T E D

AMOUNTOF CLAIM

AMOUNTENTITLED TO

PRIORITY

CREDITOR'S NAME,MAILING ADDRESS

INCLUDING ZIP CODE,AND ACCOUNT NUMBER(See instruct ion s above.)

DATE CLAIM WASINCURRED AND

CONSIDERATIONFOR CLAIM

AMOUNTNOT

ENTITLED PRIORITY

ANY

ACCOUNT NO.$0.0

$Sheet no. 1 of 1 continuation sheets attached to Schedule ofCreditors Holding Priority Claims

Subtotals(Totals of this page)

0.000.00 0$ $

Total(Use only on last page of the completedSchedule E. Report also on the Summary ofSchedules.)

0.00

0.00

Total(Use only on last page of the completedSchedule E. If applicable, report also on theStatistical Summary of Certain Liabilities andRelated Data. )

0

$

$$



13/43

,

B6F (Official Form 6F) (12/07)

In re Case No.


Debtor

SCHEDULE F - CREDITORS HOLDING UNSECURED NONPRIORITY CLAIMS

Check this box if debtor has no creditors holding unsecured claims to report on this Schedule F.


CONSIDERATION FORCLAIM.

IF CLAIM IS SUBJECT TOSETOFF, SO STATE


INCLUDING ZIP CODE,AND ACCOUNT NUMBER(See instructions above.)

AMOUNT OFCLAIM

C O D E B T O R

H U S B A N D , W I F E , J O I N

T


C O N T I N G E N T


D I S P U T E D

10,000.00870005 755 ACCOUNT NO.

ACS/Student Capital501 Bleecker StreetUtica, NY 13501

Student Loans

5,100.0041317604 ACCOUNT NO.

Asset Acceptancec/o Fulton, Friedman, & Gullace6100 Oak Tree Blvd. SSuite 200Cleveland, OH 44131

Asset AcceptancePO Box 2039Warren, MI 48090-2039

Collection Account

Judgment 2011 CVF 00322

(for Citibank 5424180682575029)

150.001-836.0 ACCOUNT NO.

Canfield Counseling3974 Boardman-Canfield RoadCanfield, OH 44406

Medical bill

Continuation sheets attached3

15,250.00Subtotal $

Total $

(Use only on last page of the completed Schedule F.)(Report also on Summary of Schedules and, if applicable on the Statistical

Summary of Certain Liabilities and Related Data.)



14/43

B6F (Official Form 6F) (12/07) - Cont.

,In re Case No.


Debtor

SCHEDULE F - CREDITORS HOLDING UNSECURED NONPRIORITY CLAIMS(Continuation Sheet)






AMOUNT OFCLAIM

C O D E B T O R

H U S B A N D , W I F

E , J O I N T

O R C O M M U

N I T Y

C O N T I N G E N T

U N L I Q U I D A

T E D

D I S P U T E

D

2,700.00486236259438**** ACCOUNT NO.

Capital Onec/o Javitch, Block & Rathbone

1100 Superior Avenue19th Floor Cleveland, OH 44114

Capital OnePO Box 30285Salt Lake City, UT 84130-0285

Judgment 11 CVF 00777

Credit Card

800.00189818989031**** ACCOUNT NO.

Dominion East Ohioc/o Alliance One Receivables4850 E. Street Road, Suite 300Trevose, PA 19053

Dominion East Ohioc/o Alliance One1684 Woodlands Drive, Suite 150Maumee, OH 43537

Dominion East OhioPO Box 26666Richmond, VA 23261

Collection Account

Utility Bill

200.0011005983**** ACCOUNT NO.

First Energy Service Co.c/o Portfolio Recovery Services120 Corporate Blvd., #100Norfolk, VA 23502

Collection Company

Utility

3,700.00SubtotalSheet no. 1 of 3 continuation sheets attached to Schedule of CreditorsHolding UnsecuredNonpriority Claims

$

Total $





15/43


,In re Case No.


Debtor







AMOUNT OFCLAIM

C O D E B T O R


E , J O I N T

O R C O M M U

N I T Y

C O N T I N G E N T

U N L I Q U I D A

T E D

D I S P U T E

D

1,100.004695965000884193 ACCOUNT NO.

Juniper Bank/Barclay'sc/o Financial Recovery Services

PO Box 385908Minneapolis, MN 55438-5908

Juniper Bank/Barclay'sCard ServicesPO Box 882Wilmington, DE 19899-8802

Collection Account File No. BTS944

Credit Card

1,000.00604407102166**** ACCOUNT NO.

Paypal / GECRBc/o Midland Funding8875 Aero Drive, .#200San Diego, CA 92123

Paypal / GECRBAttn: Bankruptcy Dept.PO Box 103104Roswell, GA 30076

Collection Account

Credit Card

3,700.004311966068119666 ACCOUNT NO.

PNC Bankc/o Credit Collection ServicesTwo Wells AvenueNewton, MA 02459

PNC BankOne Financial ParkwayZ1-YB43-02-1Kalamazoo, MI 49009

Collection Account No. 09005501835

Credit Card

5,800.00SubtotalSheet no. 2 of 3 continuation sheets attached to Schedule of CreditorsHolding UnsecuredNonpriority Claims

$

Total $





16/43


,In re Case No.


Debtor







AMOUNT OFCLAIM

C O D E B T O R


E , J O I N T

O R C O M M U

N I T Y

C O N T I N G E N T

U N L I Q U I D A

T E D

D I S P U T E

D

200.003400 ACCOUNT NO.

Progressive Insurance Companyc/o Credit Collection ServicePO Box 9134Needham, MA 02494-9134

Collection Account

Insurance

200.0068332819**** ACCOUNT NO.

Sprintc/o Convergent Outsourcing500 SW 7th StreetBldg. A 100Renton, WA 98055-2984

Sprint800 SW 39th StreetRenton, WA 98057

Collection Account

Telephone service

150.005697510095 ACCOUNT NO.

Time Warner Cablec/o Prompt Recovery Services9347 Ravenna RoadSuite 6Twinsburg, OH 44087

Time Warner Cable3140 W. Arrowood Road

Charlotte, NC 28273

Collection Account

Utility Bill

550.00SubtotalSheet no. 3 of 3 continuation sheets attached to Schedule of CreditorsHolding UnsecuredNonpriority Claims

$

Total25,300.00

$





17/43

, Case No.In re:

B6G (Official Form 6G) (12/07)

(If known)

David J. PokrivnakDebtor

SCHEDULE G - EXECUTORY CONTRACTS AND UNEXPIRED LEASES

Check this box if debtor has no executory contracts or unexpired leases.

NAME AND MAILING ADDRESS, INCLUDING ZIP CODE,OF OTHER PARTIES TO LEASE OR CONTRACT.

DESCRIPTION OF CONTRACT OR LEASE AND NATURE OFDEBTOR'S INTEREST, STATE WHETHER LEASE IS FOR

NONRESIDENTIAL REAL PROPERTY. STATE CONTRACTNUMBER OF ANY GOVERNMENT CONTRACT.



18/43

B6H (Official Form 6H) (12/07)

Case No.In re:, (If known)

David J. Pokrivnak

Debtor

SCHEDULE H - CODEBTORS Check this box if debtor has no codebtors.

NAME AND ADDRESS OF CODEBTOR NAME AND ADDRESS OF CREDITOR



19/43

B6I (Official Form 6I) (12/07)

Case No.In re ,David J. Pokrivnak

Debtor (If known)

SCHEDULE I - CURRENT INCOME OF INDIVIDUAL DEBTOR(S)The column labeled “Spouse” must be completed in all cases filed by joint debtors and by every married debtor, whether or not a joint petition isfiled, unless the spouses are separated and a joint petition is not filed. Do not state the name of any minor child. The average monthly incomecalculated on this form may differ from the current monthly income calculated on Form 22A, 22B, or 22C.

Debtor’s MaritalStatus: DEPENDENTS OF DEBTOR AND SPOUSESingle

RELATIONSHIP(S): AGE(S):

DEBTOR SPOUSE

Occupation

How long employed

Address of Employer

Unemployed

Name of Employer

Employment:

INCOME: (Estimate of average or projected monthly income at time case filed) DEBTOR SPOUSE

3. SUBTOTAL

4. LESS PAYROLL DEDUCTIONS

0.00 b. Insurance0.00$ c. Union dues $

$$0.00 a. Payroll taxes and social security $ $

2. Estimate monthly overtime 0.00 $

0.00 $$ (Prorate if not paid monthly.)

0.00 $$

1. Monthly gross wages, salary, and commissions

$

d. Other (Specify) $ $0.00

5. SUBTOTAL OF PAYROLL DEDUCTIONS

11. Social security or other government assistance

debtor’s use or that of dependents listed above. $ $10. Alimony, maintenance or support payments payable to the debtor for the

$ $

8. Income from real property $ $

$(Attach detailed statement) $

7. Regular income from operation of business or profession or farm

6. TOTAL NET MONTHLY TAKE HOME PAY $ $

$ $

(Specify) $ $

9. Interest and dividends

0.00

0.00

0.00

0.00

0.00

0.00

0.00

$ $0.0012. Pension or retirement income

0.00 $$(Specify)

13. Other monthly income

15. AVERAGE MONTHLY INCOME (Add amounts shown on lines 6 and 14) 0.00 $$

0.00 $$

16. COMBINED AVERAGE MONTHLY INCOME: (Combine columntotals from line 15)

$ 0.00

(Report also on Summary of Schedules and, if applicable, onStatistical Summary of Certain Liabilities and Related Data)

14. SUBTOTAL OF LINES 7 THROUGH 13

17. Describe any increase or decrease in income reasonably anticipated to occur within the year following the filing of this document.:

NONE



20/43

B6J (Official Form 6J) (12/07)

(If known)Debtor

David J. Pokrivnak Case No.In re ,

SCHEDULE J - CURRENT EXPENDITURES OF INDIVIDUAL DEBTOR(S)

Complete this schedule by estimating the average or projected monthly expenses of the debtor and the debtor’s family at time case filed.Prorate any payments made biweekly, quarterly, semi-annually, or annually to show monthly rate. The average monthly expenses calculated onthis form may differ from the deductions from income allowed on Form22A or 22C.

Check this box if a joint petition is filed and debtor's spouse maintains a separate household. Complete a separate schedule of

expenditures labeled "Spouse."

a. Are real estate taxes included?

b. Is property insurance included?

2. Utilities:

0.00

0.00

0.00

0.00No

Yes

No

1. Rent or home mortgage payment (include lot rented for mobile home) $

Yes

$ a. Electricity and heating fuel

$ b. Water and sewer

$ c. Telephone

100.00$Cell Phoned. Other

100.00

0.00

0.00

0.00

0.00

0.00

0.000.00

50.00

50.00

200.000.00

b. Life

9. Recreation, clubs and entertainment, newspapers, magazines, etc. $

$10. Charitable contributions

d. Auto

c. Health

$

a. Homeowner’s or renter’s $

11. Insurance (not deducted from wages or included in home mortgage payments)

8. Transportation (not including car payments) $$7. Medical and dental expenses

$

$

6. Laundry and dry cleaning $

$4. Food

3. Home maintenance (repairs and upkeep) $

5. Clothing $

e. Other $ 0.00

0.00

0.00

12. Taxes (not deducted from wages or included in home mortgage payments)

a. Auto

13. Installment payments: (In chapter 11, 12, and 13 cases, do not list payments to be included in the plan)

(Specify) $

$

b. Other $ 0.00

0.00

0.00

0.00$15. Payments for support of additional dependents not living at your home

$16. Regular expenses from operation of business, profession, or farm (attach detailed statement)

$14. Alimony, maintenance, and support paid to others

17. Other $ 0.00

500.00$18. AVERAGE MONTHLY EXPENSES (Total lines 1-17. Report also on Summary of Schedules and,if applicable, on the Statistical Summary of Certain Liabilities and Related Data.)

19. Describe any increase or decrease in expenditures reasonably anticipated to occur within the year following the filing of this document:

20. STATEMENT OF MONTHLY NET INCOMEa. Average monthly income from Line 15 of Schedule I $

b. Average monthly expenses from Line 18 above

c. Monthly net income (a. minus b.)

$

$ -500.00

500.00

0.00



21/43

B6 Summary (Official Form 6 - Summary) (12/07)

United States Bankruptcy Court


Case No.

Debtor 7Chapter

,In re David J. Pokrivnak

SUMMARY OF SCHEDULESIndicate as to each schedule whether that schedule is attached and state the number of pages in each. Report the totals from Schedules A, B, D, E, F, I,and J in the boxes provided. Add the amounts from Schedules A and B to determine the total amount of the debtor’s assets. Add the amounts of all claimsfrom Schedules D, E, and F to determine the total amount of the debtor’s liabilities. Individual debtors also must complete the “Statistical Summary ofCertain Liabilities and Related Data” if they file a case under chapter 7, 11, or 13.

NAME OF SCHEDULE ATTACHED(YES/NO)

NO. OF SHEETS ASSETS LIABILITIES OTHER

Real Property

Personal Property

Property Claimedas Exempt

Creditors HoldingSecured Claims

Creditors Holding UnsecuredPriority Claims(Total of Claims on Schedule E)

Creditors Holding UnsecuredNonpriority Claims

Executory Contracts andUnexpired Leases

Codebtors

Current Expenditures ofIndividual Debtor(s)

TOTAL

$

$

$

$

$

$

$

$ $

NO

YES

NO

NO

NO

YES

NO

NO

YES

YES

A -

B -

C -

D -

E -

F -

G -

H -

I -

J -

Current Income of Individual Debtor(s)

1

2

1

1

2

4

1

1

1

1

400.00 25,300.00

0.00

400.00

0.00

0.00

25,300.00

0.00

500.00

15



22/43

Form 6 - Statistical Summary (12/07)

United States Bankruptcy CourtNorthern District of Ohio

Case No.In re,

Chapter 7

David J. Pokrivnak

Debtor

STATISTICAL SUMMARY OF CERTAIN LIABILITIES AND RELATED DATA (28 U.S.C. § 159)

If you are an individual debtor whose debts are primarily consumer debts, as defined in § 101(8) of the Bankruptcy Code (11 U.S.C.§ 101(8)), filing a case under chapter 7, 11 or 13, you must report all information requested below.

Check this box if you are an individual debtor whose debts are NOT primarily consumer debts. You are not required to report anyinformation here.

This information is for statistical purposes only under 28 U.S.C. § 159.

$

$

$

$

$

$

Amount

TOTAL

Obligations to Pension or Profit-Sharing, and Other SimilarObligations (from Schedule F)

Domestic Support, Separation Agreement, and Divorce DecreeObligations Not Reported on Schedule E.

Student Loan Obligations (from Schedule F)

Claims for Death or Personal Injury While Debtor WasIntoxicated (from Schedule E) (whether disputed or undisputed)

Domestic Support Obligations (from Schedule E)

Taxes and Certain Other Debts Owed to Governmental Units (fromSchedule E)

Type of Liability

Summarize the following types of liabilities, as reported in the Schedules, and total them.

$

0.00

0.00

0.00

0.00

0.00

0.00

0.00

Current Monthly Income (from Form 22A Line 12; OR, Form22B Line 11; OR, Form 22C Line 20 )

Average Expenses (from Schedule J, Line 18)

$

$

$ Average Income (from Schedule I, Line 16)

State the following:

0.00

500.00

0.00

State the following:

1. Total from Schedule D, “UNSECURED PORTION, IF ANY”column

2. Total from Schedule E, “AMOUNT ENTITLED TO PRIORITY”column.

3. Total from Schedule E, “AMOUNT NOT ENTITLED TOPRIORITY, IF ANY” column

4. Total from Schedule F

5. Total of non-priority unsecured debt (sum of 1, 3, and 4)

$

$

$

$

$

0.00

0.00

0.00

25,300.00

25,300.00



23/43

,In re Case No.(If known)

David J. Pokrivnak

Debtor

B6 Declaration (Official Form 6 - Declaration) (12/07)

DECLARATION CONCERNING DEBTOR'S SCHEDULES

DECLARATION UNDER PENALTY OF PERJURY BY INDIVIDUAL DEBTOR

sheets, and that they are true and correct to the best of my knowledge, information, and belief. I declare under penalty of perjury that I have read the foregoing summary and schedules, consisting of 17

Date: Signature:

David J. Pokrivnak

s/ David J. Pokrivnak11/20/2012

Debtor

[If joint case, both spouses must sign]

Penalty for making a false statement or concealing property: Fine of up to $500,000 or imprisonment for up to 5 years or both. 18 U.S.C §§ 152 and3571.



24/43

B7 (Official Form 7) (4/10)

UNITED STATES BANKRUPTCY COURT


Case No.In re:,

(If known)

David J. Pokrivnak

Debtor

STATEMENT OF FINANCIAL AFFAIRS

1. Income from employment or operation of business

State the gross amount of income the debtor has received from employment, trade, or profession, or from operation of thedebtor's business, including part-time activities either as an employee or in independent trade or business, from the beginningof 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 afiscal rather than a calendar year may report fiscal year income. Identify the beginning and ending dates of the debtor's fiscalyear.) If a joint petition is filed, state income for each spouse separately. (Married debtors filing under chapter 12 or chapter 13must state income of both spouses whether or not a joint petition is filed, unless the spouses are separated and a joint petitionis not filed.)

None

FISCAL YEAR PERIODSOURCE AMOUNT

2. Income other than from employment or operation of business

State the amount of income received by the debtor other than from employment, trade, profession, operation of the debtor'sbusiness during the two years immediately preceding the commencement of this case. Give particulars. If a joint petition isfiled, state income for each spouse separately. (Married debtors filing under chapter 12 or chapter 13 must state income foreach spouse whether or not a joint petition is filed, unless the spouses are separated and a joint petition is not filed.)

None

FISCAL YEAR PERIODSOURCE AMOUNT

3. Payments to creditors

Comp lete a. or b ., as approp r iate, and c.

None

NAME AND ADDRESS OFCREDITOR

DATES OFPAYMENTS

AMOUNTPAID

AMOUNT

STILL OWING

a. Individual or joint debtor(s) with primarily consumer debts: List all payments on loans, installment purchases of goods orservices, and other debts to any creditor made within 90 days immediately preceding the commencement of this case unlessthe 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 alternativerepayment schedule under a plan by an approved nonprofit budgeting and credit counseling agency. (Married debtors filingunder chapter 12 or chapter 13 must include payments by either or both spouses whether or not a joint petition is filed, unlessthe spouses are separated and a joint petition is not filed.)



25/43

2

None b. Debtor whose debts are not primarily consumer debts: List each payment or other transfer to any creditor made within 90days immediately preceding the commencement of the case unless the aggregate value of all property that constitutes or isaffected by such transfer is less than $5,850*. If the debtor is an individual, indicate with an asterisk (*) any payments thatwere made to a creditor on account of a domestic support obligation or as part of an alternative repayment schedule under aplan by an approved nonprofit budgeting and credit counseling agency. (Married debtors filing under chapter 12 or chapter 13must include payments and other transfers by either or both spouses whether or not a joint petition is filed, unless thespouses are separated and a joint petition is not filed.)

NAME AND ADDRESS OF CREDITOR DATES OFPAYMENTS/TRANSFERS

AMOUNTPAID ORVALUE OFTRANSFERS

AMOUNT

STILL

OWING

*Amount subject to adjustment on 4/01/13, and every three years thereafter with respect to cases commenced on or after the dateof adjustment.

None

NAME AND ADDRESS OF CREDITOR AND RELATIONSHIP TO DEBTOR

DATE OFPAYMENT

AMOUNT AMOUNTSTILL OWINGPAID

c. All debtors: List all payments made within one year immediately preceding the commencement of this case to or for thebenefit 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 the spouses are separated and a joint petition isnot filed.)

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 thefiling of this bankruptcy case. (Married debtors filing under chapter 12 or chapter 13 must include information concerningeither 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

AND CASE NUMBER NATURE OF PROCEEDINGCOURT OR AGENCY AND LOCATION

STATUS ORDISPOSITION

Captial One Bank v. David J.Pokrivnak 2011 CVF 00777

Boardman CourtBoardman, OH

Complaint Judgment11/03/2011

Asset Acceptance vs. DavidPokrivnak CVF 1100322

Struthers Municipal CourtStruthers, OH

Complaint Judgment07/13/2011

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 includeinformation 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 DESCRIPTION

OF PERSON FOR WHOSE DATE OF AND VALUE OF

BENEFIT PROPERTY WAS SEIZED SEIZURE PROPERTY



26/43

3

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 offoreclosure or returned to the seller, within one year immediately preceding the commencement of this case. (Marrieddebtors filing under chapter 12 or chapter 13 must include information concerning property of either or both spouses whetheror not a joint petition is filed, unless the spouses are separated and a joint petition is not filed.)

DATE OF REPOSSESSION, DESCRIPTION

FORECLOSURE SALE,NAME AND ADDRESS AND VALUE OF

OF CREDITOR OR SELLER TRANSFER OR RETURN PROPERTY

6. Assignments and receiverships

None a. Describe any assignment of property for the benefit of creditors made within 120 days immediately preceding thecommencement of this case. (Married debtors filing under chapter 12 or chapter 13 must include any assignment by either orboth spouses whether or not a joint petition is filed, unless the spouses are separated and a joint petition is notfiled.)

TERMS OF

ASSIGNMENTDATE OFNAME AND ADDRESS

OR SETTLEMENT ASSIGNMENTOF ASSIGNEE

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 mustinclude information concerning property of either or both spouses whether or not a joint petition is filed, unless thespouses are separated and a joint petition is not filed.)

None

DESCRIPTIONNAME AND ADDRESS

AND VALUE OFDATE OFOF COURTNAME AND ADDRESS

PROPERTYORDERCASE TITLE & NUMBEROF CUSTODIAN

7. Gifts

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 charitablecontributions aggregating less than $100 per recipient. (Married debtors filing under chapter 12 or chapter 13 must includegifts or contributions by either or both spouses whether or not a joint petition is filed, unless the spouses are separated and aoint petition is not filed.)

NAME AND ADDRESS RELATIONSHIP DESCRIPTION

OF PERSON TO DEBTOR, DATE AND VALUE OF

OR ORGANIZATION IF ANY OF GIFT GIFT

None

8. Losses

List all losses from fire, theft, other casualty or gambling within one year immediately preceding the commencementof 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 aoint petition is not filed.)

DESCRIPTION DESCRIPTION OF CIRCUMSTANCES AND, IF

AND VALUE OF LOSS WAS COVERED IN WHOLE OR IN PART DATE OF

PROPERTY BY INSURANCE, GIVE PARTICULARS LOSS

None



27/43

4

9. Payments related to debt counseling or bankruptcy

List all payments made or property transferred by or on behalf of the debtor to any persons, including attorneys, forconsultation concerning debt consolidation, relief under the bankruptcy law or preparation of a petition in bankruptcy withinone year immediately preceding the commencement of this case.

NAME AND ADDRESS DATE OF PAYMENT, AMOUNT OF MONEY OR

OF PAYEE NAME OF PAYOR IF DESCRIPTION AND VALUEOTHER THAN DEBTOR OF PROPERTY

None

10. Other transfers

DESCRIBE PROPERTY

TRANSFERREDNAME AND ADDRESS OF TRANSFEREE,

AND VALUE RECEIVEDDATERELATIONSHIP TO DEBTOR

None

a. List all other property, other than property transferred in the ordinary course of the business or financial affairs of thedebtor, 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 jointpetition is filed, unless the spouses are separated and a joint petition is not filed.)

None

TRANSFER(S)DEVICE

DATE S OF

INTEREST IN PROPERTY

NAME OF TRUST OR OTHER

AND VALUE OF PROPERTY OR DEBTOR

AMOUNT OF MONEY OR DESCRIPTION

b. List all property transferred by the debtor within ten years immediately preceding the commencement of this case to aself-settled trust or similar device of which the debtor is a beneficiary.

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 debtorsfiling under chapter 12 or chapter 13 must include information concerning accounts or instruments held by or for either or bothspouses whether or not a joint petition is filed, unless the spouses are separated and a joint petition is not filed.)

OF INSTITUTION AND AMOUNT OF FINAL BALANCE OR CLOSING

NAME AND ADDRESS DIGITS OF ACCOUNT NUMBER, DATE OF SALE

TYPE OF ACCOUNT, LAST FOUR AMOUNT AND

12. Safe deposit boxes

List each safe deposit or other box or depository in which the debtor has or had securities, cash, or other valuables withinone year immediately preceding the commencement of this case. (Married debtors filing under chapter 12 or chapter 13must include boxes or depositories of either or both spouses whether or not a joint petition is filed, unless the spouses areseparated and a joint petition is not filed.)

DESCRIPTIONNAMES AND ADDRESSESNAME AND ADDRESS DATE OF TRANSFE

OR SURRENDER,OFOF THOSE WITH ACCESSOF BANK OR

IF ANYCONTENTSTO BOX OR DEPOSITORYOTHER DEPOSITORY

None



28/43

5

13. Setoffs

List all setoffs made by any creditor, including a bank, against a debt or deposit of the debtor within 90 days precedingthe commencement of this case. (Married debtors filing under chapter 12 or chapter 13 must include informationconcerning either or both spouses whether or not a joint petition is filed, unless the spouses are separated and a jointpetition is not filed.)

AMOUNT OFDATE OF

SETOFFSETOFFNAME AND ADDRESS OF CREDITOR

None

14. Property held for another personList all property owned by another person that the debtor holds or controls.

DESCRIPTION AND VALUENAME AND ADDRESS

LOCATION OF PROPERTYOF PROPERTYOF OWNER

None

David Pokrivn262 E. Western Reserve RoadPoland, OH 44514

15. Prior address of debtor

If debtor has moved within three years immediately preceding the commencement of this case, list all premises which thedebtor occupied during that period and vacated prior to the commencement of this case. If a joint petition is filed, report alsoany separate address of either spouse.

DATES OF OCCUPANCNAME USED ADDRESS

None

16. Spouses and Former SpousesIf 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 spousewho resides or resided with the debtor in the community property state.

None

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 ofhazardous 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 orformerly 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.

a. List the name and address of every site for which the debtor has received notice in writing by a governmental unit thatit may be liable or potentially liable under or in violation of an Environmental Law. Indicate the governmental unit, the date ofthe notice, and, if known, the Environmental Law.

None

SITE NAME AND NAME AND ADDRESS DATE OF ENVIRONMENTAL

ADDRESS OF GOVERNMENTAL UNIT NOTICE LAW



29/43

6

b. List the name and address of every site for which the debtor provided notice to a governmental unit of a release ofHazardous Material. Indicate the governmental unit to which the notice was sent and the date of the notice.

None

SITE NAME AND NAME AND ADDRESS DATE OF ENVIRONMENTAL

ADDRESS OF GOVERNMENTAL UNIT NOTICE LAW

c. List all judicial or administrative proceedings, including settlements or orders, under any Environmental Law withrespect to which the debtor is or was a party. Indicate the name and address of the governmental unit that is or was a partyto the proceeding, and the docket number.

None

NAME AND ADDRESS DOCKET NUMBER STATUS OR

DISPOSITIONOF GOVERNMENTAL UNIT

18. Nature, location and name of business

If the debtor is a corporation , list the names, addresses, taxpayer identification numbers, nature of the business, andbeginning and ending dates of all businesses in which the debtor was a partner or owned 5 percent or more of the voting orequity 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.

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 managingexecutive of a corporation, partner in a partnership, sole proprietor, or was self-employed in a trade, profession, or other activity either full- or part-time within the 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 immediatelypreceding the commencement of this case.

None

LAST FOUR DIGITSOF SOCIAL SECURITYOR OTHER INDIVIDUALTAXPAYER-I.D. NO.(ITIN)/ COMPLETE EIN

BEGINNING AND ENDIN ADDRESS

DATESNAME NATURE OF

BUSINESS

b. Identify any business listed in response to subdivision a., above, that is "single asset real estate" as defined in 11U.S.C. § 101.

None

ADDRESSNAME

* * * * * *

I declare under penalty of perjury that I have read the answers contained in the foregoing statement

11/20/2012 s/ David J. Pokrivnak

of financial affairs and any attachments thereto and that they are true and correct.

Date Signatureof Debtor David J. Pokrivnak

[if completed by an individual or individual and spouse]



30/43

B 8 (Official Form 8) (12/08)

UNITED STATES BANKRUPTCY COURTNorthern District of Ohio

Debtor

In re Case No.,David J. PokrivnakChapter 7

CHAPTER 7 INDIVIDUAL DEBTOR'S STATEMENT OF INTENTION

PART A – Debts secured by property of the estate. (Part A must be fully completed for EACH debt which is securedby property of the estate. Attach additional pages if necessary.)

Property No. 1

Describe Property Securing Debt:Creditor's Name:

None

Other. Explain ___________________________ (for example, avoid lien using 11 U.S.C. § 522(f))

Reaffirm the debt

Redeem the property

If retaining the property, I intend to (check at least one):

RetainedSurrendered

Property will be (check one):

Property is (check one):

Claimed as exempt Not claimed as exempt

PART B – Personal property subject to unexpired leases. (All three columns of Part B must be completed for each unexpired lease. Attach additional pages if necessary.)

Property No. 1

Lessor's Name: Describe Leased Property: Lease will be Assumed pursuantto 11 U.S.C. § 365(p)(2):

YES NONone

continuation sheets attached (if any)0

I declare under penalty of perjury that the above indicates my intention as to any property of my estatesecuring a debt and/or personal property subject to an unexpired lease.

11/20/2012Date: s/ David J. Pokrivnak

David J. PokrivnakSignature of Debtor



31/43

B22A (Official Form 22A) (Chapter 7) (12/10)

David J. PokrivnakIn re

According to the information required to be entered on thisstatement (check one box as directed in Part I, III, or VI of thisstatement):

Case Number:(If known)

The presumption does not arise

Debtor(s) The presumption arises

The presumption is temporarily inapplicable.

CHAPTER 7 STATEMENT OF CURRENT MONTHLY INCOMEAND MEANS-TEST CALCULATION

In addition to Schedules I and J, this statement must be completed by every individual chapter 7 debtor. If none of the exclusions inPart I applies, joint debtors may complete one statement only. If any of the exclusions in Part I applies, joint debtors should completeseparate statements if they believe this is required by § 707(b)(2)(C).

Part I. MILITARY AND NON-CONSUMER DEBTORS

Disabled Veterans. If you are a disabled veteran described in the Declaration in this Part IA, (1) check the box at thebeginning of the Declaration, (2) check the box for “The presumption does not arise” at the top of this statement, and (3)complete the verification in Part VIII. Do not complete any of the remaining parts of this statement.

Declaration of Disabled Veteran. By checking this box, I declare under penalty of perjury that I am a disabled veteran

(as defined in 38 U.S.C. § 3741(1)) whose indebtedness occurred primarily during a period in which I was on active duty (asdefined in 10 U.S.C. § 101(d)(1)) or while I was performing a homeland defense activity (as defined in 32 U.S.C. §901(1)).

1A

Non-consumer Debtors. If your debts are not primarily consumer debts, check the box below and complete theverification in Part VIII. Do not complete any of the remaining parts of this statement.

Declaration of non-consumer debts. By checking this box, I declare that my debts are not primarily consumer debts.

1B

1C

Reservists and National Guard Members; active duty or homeland defense activity. Members of a reservecomponent of the Armed Forces and members of the National Guard who were called to active duty (as defined in 10U.S.C. § 101(d)(1)) after September 11, 2001, for a period of at least 90 days, or who have performed homeland defenseactivity (as defined in 32 U.S.C. § 901(1)) for a period of at least 90 days, are excluded from all forms of means testingduring the time of active duty or homeland defense activity and for 540 days thereafter (the “exclusion period”). If youqualify for this temporary exclusion, (1) check the appropriate boxes and complete any required information in theDeclaration of Reservists and National Guard Members below, (2) check the box for “The presumption is temporarilyinapplicable” at the top of this statement, and (3) complete the verification in Part VIII. During your exclusion period youare not required to complete the balance of this form, but you must complete the form no later than 14 days afterthe date on which your exclusion period ends, unless the time for filing a motion raising the means testpresumption expires in your case before your exclusion period ends.

Declaration of Reservists and National Guard Members. By checking this box and making the appropriate entriesbelow, I declare that I am eligible for a temporary exclusion from means testing because, as a member of a reservecomponent of the Armed Forces or the National Guard

a.

b.

I was called to active duty after September 11, 2001, for a period of at least 90 days and

I remain on active duty /or/

I was released from active duty on ________________ , which is less than 540 days before this

bankruptcy case was filed;OR

I am performing homeland defense activity for a period of at least 90 days /or/

I performed homeland defense activity for a period of at least 90 days, terminating on _______________ , which is less than 540 days before this bankruptcy case was filed.

Part II. CALCULATION OF MONTHLY INCOME FOR § 707(b)(7) EXCLUSION



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B22A (Official Form 22A) (Chapter 7) (12/10) 2

Marital/filing status. Check the box that applies and complete the balance of this part of this statement as directed.

b. Married, not filing jointly, with declaration of separate households. By checking this box, debtor declares underpenalty of perjury: "My spouse and I are legally separated under applicable non-bankruptcy law or my spouseand I are living apart other than for the purpose of evading the requirements of § 707(b)(2)(A) of the BankruptcyCode." Complete only Column A ("Debtor's Income") for Lines 3-11.

c. Married, not filing jointly, without the declaration of separate households set out in line 2.b above. Complete

both Column A ("Debtor's Income") and Column B ("Spouse's Income") for Lines 3-11.

a. Unmarried. Complete only Column A ("Debtor's Income") for Lines 3-11.

d. Married, filing jointly. Complete both Column A ("Debtor's Income") and Column B ("Spouse's Income") forLines 3-11.

2

Column BSpouse'sIncome

Column ADebtor'sIncome

All figures must reflect average monthly income received from all sources, derived during thesix calendar months prior to filing the bankruptcy case, ending on the last day of the monthbefore the filing. If the amount of monthly income varied during the six months, you mustdivide the six-month total by six, and enter the result on the appropriate line.

Gross wages, salary, tips, bonuses, overtime, commissions.3 0.00$ $

4

Income from the operation of a business, profession or farm. Subtract Line b fromLine a and enter the difference in the appropriate column(s) of Line 4. If you operate morethan one business, profession or farm, enter aggregate numbers and provide details on anattachment. Do not enter a number less than zero. Do not include any part of the business

expenses entered on Line b as a deduction in Part V.

0.00

0.00

$

$

$$0.00

b.

a.

c.

Gross Receipts

Ordinary and necessary business expenses

Business income Subtract Line b from Line a

Rent and other real property income. Subtract Line b from Line a and enter the difference inthe appropriate column(s) of Line 5. Do not enter a number less than zero. Do not includeany part of the operating expenses entered on Line b as a deduction in Part V.

a.

b.

c.

Gross Receipts

Ordinary and necessary operating expenses

Rent and other real property income Subtract Line b from Line a0.00$ $

$

$

0.00

0.00

5

Interest, dividends, and royalties.6 0.00$ $

Pension and retirement income.7 0.00 $$

$ $0.008 Any amounts paid by another person or entity, on a regular basis, for the household

expenses of the debtor or the debtor’s dependents, including child support paid for that purpose. Do not include alimony or separate maintenance payments or amounts paid byyour spouse if Column B is completed. Each regular payment should be reported in only onecolumn; if a payment is listed in Column A, do not report that payment in Column B.

Unemployment compensation claimed tobe a benefit under the Social Security Act Debtor Spouse $$$ $

Unemployment compensation. Enter the amount in the appropriate column(s) of Line 9.However, if you contend that unemployment compensation received by you or your spousewas a benefit under the Social Security Act, do not list the amount of such compensation inColumn A or B, but instead state the amount in the space below:9

Income from all other sources. Specify source and amount. If necessary, list additionalsources on a separate page. Do not include alimony or separate maintenance paymentspaid by your spouse if Column B is completed, but include all other payments ofalimony or separate maintenance. Do not include any benefits received under the SocialSecurity Act or payments received as a victim of a war crime, crime against humanity, or as avictim of international or domestic terrorism.

10



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$a.

Total and enter on Line 10. $$0.00

$$0.0011Subtotal of Current Monthly Income for § 707(b)(7). Add Lines 3 thru 10 in Column A, and,if Column B is completed, add Lines 3 thru 10 in Column B. Enter the total(s).

$ 0.0012

Total Current Monthly Income for § 707(b)(7). If Column B has been completed, add Line11, Column A to Line 11, Column B, and enter the total. If Column B has not been completed,enter the amount from Line 11, Column A.

Part III. APPLICATION OF § 707(b)(7) EXCLUSION

Annualized Current Monthly Income for § 707(b)(7). Multiply the amount from Line 12 by the number 12 andenter the result.

Applicable median family income. Enter the median family income for the applicable state and household size. (Thisinformation is available by family size at www.usdoj.gov/ust/ or from the clerk of the bankruptcy court.)

Application of Section 707(b)(7). Check the applicable box and proceed as directed.

The amount on Line 13 is less than or equal to the amount on Line 14. Check the box for “The presumption does notarise” at the top of page 1 of this statement, and complete Part VIII; do not complete Parts IV, V, VI or VII.

The amount on Line 13 is more than the amount on Line 14. Complete the remaining parts of this statement.

13

14

15

0.00

40,471.00

$

$a. Enter debtor’s state of residence: b. Enter debtor’s household size:OH 1

Complete Parts IV, V, VI, and VII of this statement only if required. (See Line 15).

a. $

$

17

16

Marital adjustment. If you checked the box at Line 2.c, enter on Line 17 the total of any income listed inLine 11, Column B that was NOT paid on a regular basis for the household expenses of the debtor or thedebtor’s dependents. Specify in the lines below the basis for excluding the Column B income (such aspayment of the spouse’s tax liability or the spouse’s support of persons other than the debtor or the debtor’sdependents) and the amount of income devoted to each purpose. If necessary, list additional adjustments ona separate page. If you did not check box at Line 2.c, enter zero.

Enter the amount from Line 12.

Part IV. CALCULATION OF CURRENT MONTHLY INCOME FOR § 707(b)(2)

Total and enter on Line 17 . $

Current monthly income for § 707(b)(2). Subtract Line 17 from Line 16 and enter the result.18 $

Subpart A: Deductions under Standards of the Internal Revenue Service (IRS)

Part V. CALCULATION OF DEDUCTIONS FROM INCOME

19A

National Standards: food, clothing and other items. Enter in Line 19A the “Total” amount from IRSNational Standards for Food, Clothing and Other Items for the applicable number of persons. (Thisinformation is available at www.usdoj.gov/ust/ or from the clerk of the bankruptcy court.) The applicablenumber of persons is the number that would currently be allowed as exemptions on your federal income taxreturn, plus the number of any additional dependents whom you support.

$



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19BNational Standards: health care. Enter in Line a1 below the amount from IRS National Standards for Outof-Pocket Health Care for persons under 65 years of age, and in Line a2 the IRS National Standards for Outof-Pocket Health Care for persons 65 years of age or older. (This information is available at www.usdoj.gov/ust/or from the clerk of the bankruptcy court.) Enter in Line b1 the applicable number of persons who are under 65 years of age, and enter in Line b2 the applicable number of persons who are 65 years of age or older.(The applicable number of persons in each age category is the number in that category that would currentlybe allowed as exemptions on your federal income tax return, plus the number of any additional dependentswhom you support.) Multiply Line a1 by Line b1 to obtain a total amount for persons under 65, and enter theresult in Line c1. Multiply Line a2 by Line b2 to obtain a total amount for persons 65 and older, and enter theresult in Line c2. Add Lines c1 and c2 to obtain a total health care amount, and enter the result in Line 19B.

Persons under 65 years of age Persons 65 years of age or older

c2.

b2.

a2.

c1.

b1.

a1.

$

Allowance per person

Number of persons

Subtotal

Allowance per person

Number of persons

Subtotal

20A

Local Standards: housing and utilities; non-mortgage expenses. Enter the amount of the IRS Housingand Utilities Standards; non-mortgage expenses for the applicable county and family size. (This information isavailable at www.usdoj.gov/ust/ or from the clerk of the bankruptcy court). The applicable family size consistsof the number that would currently be allowed as exemptions on your federal income tax return, plus thenumber of any additional dependents whom you support. $

Local Standards: housing and utilities; mortgage/rent expense. Enter, in Line a below, the amount ofthe IRS Housing and Utilities Standards; mortgage/rent expense for your county and family size (thisinformation is available at www.usdoj.gov/ust/ or from the clerk of the bankruptcy court)(the applicablefamily size consists of the number that would currently be allowed as exemptions on your federal income taxreturn, plus the number of any additional dependents whom you support); enter on Line b thetotal of the Average Monthly Payments for any debts secured by your home, as stated in Line 42; subtractLine b from Line a and enter the result in Line 20B. Do not enter an amount less than zero.

20B

$a. IRS Housing and Utilities Standards; mortgage/rental

expense

$

$b.

c.

Average Monthly Payment for any debts secured by home, ifany, as stated in Line 42.Net mortgage/rental expense Subtract Line b from Line a

21

Local Standards: housing and utilities; adjustment. If you contend that the process set out in Lines 20Aand 20B does not accurately compute the allowance to which you are entitled under the IRS Housing andUtilities Standards, enter any additional amount to which you contend you are entitled, and state the basis for our contention in the s ace below:

$

Documents

David j Pokrivnak - Chapter 7 Bankruptcy