Form 105 Worksheet - Involuntary Petition Against an Individual

Worksheet only. Not the official form. Transfer to Official Form 105 for involuntary petitions against individuals.

United States Bankruptcy Court
District of [District]

Debtor Information

• Debtor name: [ ]
• Other names used in last 8 years (including married/maiden/trade names): [ ]
• Last 4 digits of SSN/ITIN: [ ]
• Any EINs (if applicable): [ ]
• Residence address: [ ]
• Mailing address (if different): [ ]
• County: [ ]

Petitioning Creditors

List at least three creditors (unless eligible for two-creditor rule) holding unsecured claims that are not contingent, not subject to bona fide dispute, and aggregate at least the statutory threshold.

• Total of petitioning creditors’ claims: $[ ]
• If fewer than three creditors, explain eligibility (e.g., fewer than 12 creditors): [ ]

Chapter Selection

• Chapter requested: [ ] 7 [ ] 11

Grounds for Involuntary Relief

• Debtor is generally not paying debts as they become due (exclude disputed/contingent debts). [Yes/No]
• Custodian/receiver appointed or took possession within 120 days prepetition. [Yes/No]
• Brief factual basis supporting grounds: [ ]

Property Custodian (if any)

• Name of custodian/receiver: [ ]
• Court/case number/appointment date: [ ]
• Property in custodian’s possession: [ ]

Request for Order for Relief

• Petitioners request entry of order for relief under the chapter checked above.

Signature of Each Petitioner (attach additional pages if needed)

• Creditor name: [ ]
• Signature: __________________________ Date: __________
• Printed name/title/relationship (if agent): [ ]
• Address/Phone/Email: [ ]

Attorney for Petitioners (if any)

• Name/Bar #: [ ]
• Firm/Address: [ ]
• Phone/Email: [ ]
• Signature: __________________________ Date: __________