Form 201 Worksheet - Voluntary Petition for Non-Individuals Filing for Bankruptcy

Worksheet only. Not the official form. Transfer to Official Form 201 or e-filing software. For corporations, LLCs, partnerships, and other non-individual debtors.

United States Bankruptcy Court
District of [District] (State: [State])

Debtor Name: [Exact legal name of debtor]
Other names you have used in the last 8 years: [ ]
Debtor’s website (URL): [ ]
All federal EIN(s) (last 4 digits if full not available): [ ]
Street address (principal place of business): [ ]
Mailing address (if different): [ ]
Location of principal assets (if different): [ ]
County of principal place of business: [ ]
Case No.: [if known]
Chapter: [7/9/11/12/15]
Check if amended filing: [ ]

Part 1: Identify the Debtor

• Type of debtor (check one): [ ] Corporation (includes LLC and LLP) [ ] Partnership [ ] Other (specify)
• 7A. Nature of business (check one):
• [ ] Health Care Business (11 U.S.C. 101(27A))
• [ ] Single Asset Real Estate (11 U.S.C. 101(51B))
• [ ] Railroad
• [ ] Stockbroker
• [ ] Commodity Broker
• [ ] Clearing Bank
• [ ] None of the above
• 7B. Check all that apply:
• [ ] Tax-exempt entity under 26 U.S.C. 501(c)
• [ ] Investment company (Investment Company Act)
• [ ] Investment advisor (Investment Advisers Act)
• Tax status: [ ] Nonprofit/religious [ ] For-profit
• NAICS 4-digit code: [ ]
• Describe primary business activity (brief): [ ]
• Business location(s) (attach continuation if multiple): Address/County/State/ZIP [ ]

Part 2: Identify the Case Type

• Chapter requested: [ ] 7 [ ] 9 [ ] 11 [ ] 12 [ ] 15
• If Chapter 11:
• [ ] Debtor’s aggregate noncontingent liquidated debts (excluding insider/affiliate debt) are less than the statutory small business limit ($3,024,725, subject to periodic adjustment)
• [ ] Debtor is a small business debtor (11 U.S.C. 101(51D))
• [ ] Debtor elects to proceed under Subchapter V of Chapter 11
• [ ] Debtor is not a small business debtor
• [ ] Plan filed with petition
• [ ] Acceptances of the plan were solicited prepetition
• [ ] If small business debtor and not Subchapter V: attach most recent balance sheet, statement of operations, cash-flow statement, and federal income tax return—or a statement that none exist (11 U.S.C. 1116(1)(B))
• [ ] Debtor must file periodic reports (Form 10-K/10-Q) with the SEC (attach required statement / Form 201A equivalent)
• [ ] Debtor is a shell company as defined in SEC Rule 12b-2
• Debtor will continue operating business? [Yes/No]
• If a health care business, check: [ ] Debtor is a health care business under 11 U.S.C. 101(27A)
• If single asset real estate, check: [ ] 11 U.S.C. 101(51B) SARE
• Venue basis (check all that apply): [ ] Principal place of business in this district [ ] Principal assets in this district [ ] Affiliate/General partner case pending here
• Worksheet-only: Other statutory basis (if applicable): [ ]

Part 3: Report Related Cases

• Pending bankruptcy cases by any affiliate/owner/partnership? [Yes/No]
• If Yes, list court, case number, and relationship: [ ]
• Prior bankruptcy cases of debtor (last 8 years): [Court / Case No. / Filed / Disposition] [ ]

Part 4: Debtor's Statistical Information

• Funds will be available for distribution to unsecured creditors? [ ] Yes [ ] No
• Estimated number of creditors (check one):
• [ ] 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
• Estimated assets (check one): [ ] $0-$50k [ ] $50k-$100k [ ] $100k-$500k [ ] $500k-$1M [ ] $1M-$10M [ ] $10M-$50M [ ] $50M-$100M [ ] $100M-$500M [ ] $500M-$1B [ ] $1B-$10B [ ] $10B-$50B [ ] More than $50B
• Estimated liabilities (check one): [ ] $0-$50k [ ] $50k-$100k [ ] $100k-$500k [ ] $500k-$1M [ ] $1M-$10M [ ] $10M-$50M [ ] $50M-$100M [ ] $100M-$500M [ ] $500M-$1B [ ] $1B-$10B [ ] $10B-$50B [ ] More than $50B

Part 5: Property Requiring Immediate Attention (Question 12)

• Does the debtor own or have possession, custody, or control of any property that needs immediate attention? [ ] No [ ] Yes
• Reason (check all that apply):
• [ ] Poses or is alleged to pose a threat of imminent and identifiable harm to public health or safety
• [ ] Needs to be physically secured or protected from the weather
• [ ] Includes perishable goods or assets at risk of immediate deterioration
• [ ] Other (describe): [ ]
• Location of property: [ ]
• Insurance company/agent (name/phone): [ ]
• Brief description of the problem and any needed action: [ ]

Part 6: Request for Relief and Signatures

• Chapter election and relief request:
• Debtor requests relief in accordance with the chapter of title 11, United States Code, specified above.
• Check if chapter 11 plan attachment provided: [ ]
• Check if list of 20 largest unsecured creditors attached (for non-small business Ch.11): [ ]
• Declaration and signature of authorized representative of debtor (must be an officer/authorized agent):
• I have examined this petition and have a reasonable belief that the information is true and correct.
• I declare under penalty of perjury that the foregoing is true and correct.
• Executed on (MM/DD/YYYY): __________
• Signature: ______________________
• Printed name: [ ]
• Title/Position/Relationship: [ ]
• Contact phone/email (worksheet-only): [ ]
• Signature of attorney:
• Name/Bar #: [ ]
• Firm/Address: [ ]
• Phone/Email: [ ]
• Signature: ______________________ Date: __________

Warning: Bankruptcy fraud is a serious crime. 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 $500,000 or imprisonment for up to 20 years, or both. 18 U.S.C. §§ 152, 1341, 1519, and 3571.

Part 7: Additional Required Attachments Checklist

Attach or confirm the following (as applicable for non-individual petitions):
- [ ] Corporate ownership statement under FRBP 1007(a)(1) (information described in Rule 7007.1), if required
- [ ] List of equity security holders (Ch. 11; timing per Rule 1007)
- [ ] Resolution authorizing filing (if required by governing documents)
- [ ] List of creditors holding 20 largest unsecured claims (if Ch. 11 and not small business)
- [ ] Consolidated list of creditors (if jointly administered cases)
- [ ] Certification re: eligibility for small business debtor or Subchapter V (if elected)
- [ ] Creditor matrix uploaded per local rule
- [ ] Fee disclosure (if petition preparer involved)
- [ ] Any local forms required by the district