Court filing

Form 107 — USA v. Harun (Dkt. 19.1)

Filed August 31, 2023 in USA v. Harun; one of 89 filings from this case.

Record facts

Court	U.S. District Court for the Southern District of Georgia
Filed	2023-08-31

U.S. District Court for the Southern District of Georgia · No. 3:23-cr-00003-DHB-BKE · Doc. 19-1 · 2023-08-31 · Docket on CourtListener

Full text

Official Form 107
Statement of Financial Affairs for Individuals Filing for Bankruptcy
page 1
2IILFLDO)RUP 107
Statement of Financial Affairs for Individuals Filing for Bankruptcy

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:
Give Details About Your Marital Status and Where You Lived Before
1. What is your current marital status?
Married
Not married
2. During the last 3 years, have you lived anywhere other than where you live now?
No
Yes. List all of the places you lived in the last 3 years. Do not include where you live now.
Debtor 1:
Dates Debtor 1
lived there
Debtor 2:
Dates Debtor 2
lived there
__________________________________________
Number
Street
__________________________________________
__________________________________________
City
State ZIP Code
From
________
To
________
Same as Debtor 1
___________________________________________
Number Street
___________________________________________
___________________________________________
City
State ZIP Code
Same as Debtor 1
From ________
To
________
__________________________________________
Number
Street
__________________________________________
__________________________________________
City
State ZIP Code
From
________
To
________
Same as Debtor 1
___________________________________________
Number Street
___________________________________________
___________________________________________
City
State
ZIP Code
Same as Debtor 1
From ________
To
________
3. Within the last 8 years, did you ever live with a spouse or legal equivalent in a community property state or territory? (Community property
states and territories include Arizona, California, Idaho, Louisiana, Nevada, New Mexico, Puerto Rico, Texas, Washington, and Wisconsin.)
No
Yes. Make sure you fill out Schedule H: Your Codebtors (Official Form 106H).
Part 2:
Explain the Sources of Your Income
Debtor 1
__________________________________________________________________
First Name
Middle Name
Last Name
Debtor 2
________________________________________________________________
(Spouse, if filing)
First Name
Middle Name
Last Name
United States Bankruptcy Court for the: __________ District of ______________
Case number ___________________________________________
(If known)
Fill in this information to identify your case:
Check if this is an
amended filing
__________ District of __________
Case 3:23-cr-00003-DHB-BKE Document 19-1 Filed 08/31/23 Page 1 of 12

Debtor 1
_______________________________________________________
Case number (if known)_____________________________________
First Name
Middle Name
Last Name
2IILFLDO)RUP
Statement of Financial Affairs for Individuals Filing for Bankruptcy
page 2
4. Did you have any income from employment or from operating a business during this year or the two previous calendar years?
Fill in the total amount of income you received from all jobs and all businesses, including part-time activities.
If you are filing a joint case and you have income that you receive together, list it only once under Debtor 1.
No
Yes. Fill in the details.
Debtor 1
Debtor 2
Sources of income
Check all that apply.
Gross income
(before deductions and
exclusions)
Sources of income
Check all that apply.
Gross income
(before deductions and
exclusions)
From January 1 of current year until
the date you filed for bankruptcy:
Wages, commissions,
bonuses, tips
Operating a business
$________________ Wages, commissions,
bonuses, tips
Operating a business
$________________
For last calendar year:
(January 1 to December 31, _________)
YYYY
Wages, commissions,
bonuses, tips
Operating a business
$________________
Wages, commissions,
bonuses, tips
Operating a business
$________________
For the calendar year before that:
(January 1 to December 31, _________)
YYYY
Wages, commissions,
bonuses, tips
Operating a business
$________________
Wages, commissions,
bonuses, tips
Operating a business
$________________
5. Did you receive any other income during this year or the two previous calendar years?
Include income regardless of whether that income is taxable. Examples of other income are alimony; child support; Social Security,
unemployment, and other public benefit payments; pensions; rental income; interest; dividends; money collected from lawsuits; royalties; and
gambling and lottery winnings. If you are filing a joint case and you have income that you received together, list it only once under Debtor 1.
List each source and the gross income from each source separately. Do not include income that you listed in line 4.
No
Yes. Fill in the details.
Debtor 1
Debtor 2
Sources of income
Describe below.
Gross income from
each source
(before deductions and
exclusions)
Sources of income
Describe below.
Gross income from
each source
(before deductions and
exclusions)
From January 1 of current year until
the date you filed for bankruptcy:
__________________
__________________
__________________
$_________________
$_________________
$_________________
_____________________
_____________________
_____________________
$_________________
$_________________
$_________________
For last calendar year:
(January 1 to December 31, ______)
YYYY
__________________
__________________
__________________
$_________________
$_________________
$_________________
_____________________
_____________________
_____________________
$_________________
$_________________
$_________________
For the calendar year before that:
(January 1 to December 31, ______)
YYYY
__________________
__________________
__________________
$_________________
$_________________
$_________________
_____________________
_____________________
_____________________
$_________________
$_________________
$_________________
Case 3:23-cr-00003-DHB-BKE Document 19-1 Filed 08/31/23 Page 2 of 12

Debtor 1
_______________________________________________________
Case number (if known)_____________________________________
First Name
Middle Name
Last Name
2IILFLDO)RUP
Statement of Financial Affairs for Individuals Filing for Bankruptcy
page 3
Part 3:
List Certain Payments You Made Before You Filed for Bankruptcy
6. Are either Debtor 1’s or Debtor 2’s debts primarily consumer debts?
No. Neither Debtor 1 nor Debtor 2 has 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.”
During the 90 days before you filed for bankruptcy, did you pay any creditor a total of $6,25* or more?
No. Go to line 7.
Yes. List below each creditor to whom you paid a total of $6,25* or more in one or more payments and the
total amount you paid that creditor. Do not include payments for domestic support obligations, such as
child support and alimony. Also, do not include payments to an attorney for this bankruptcy case.
* Subject to adjustment on 4/01/ and every 3 years after that for cases filed on or after the date of adjustment.
Yes. Debtor 1 or Debtor 2 or both have primarily consumer debts.
During the 90 days before you filed for bankruptcy, did you pay any creditor a total of $600 or more?
No. Go to line 7.
Yes. List below each creditor to whom you paid a total of $600 or more and the total amount you paid that
creditor. Do not include payments for domestic support obligations, such as child support and
alimony. Also, do not include payments to an attorney for this bankruptcy case.
____________________________________
Creditor’s Name
____________________________________
Number
Street
____________________________________
____________________________________
City
State
ZIP Code
Dates of
payment
Total amount paid
Amount you still owe
Was this payment for…
_________
_________
_________
$_________________ $__________________
Mortgage
Car
Credit card
Loan repayment
Suppliers or vendors
Other ____________
____________________________________
Creditor’s Name
____________________________________
Number
Street
____________________________________
____________________________________
City
State
ZIP Code
_________
_________
_________
$_________________ $__________________
Mortgage
Car
Credit card
Loan repayment
Suppliers or vendors
Other ____________
____________________________________
Creditor’s Name
____________________________________
Number
Street
____________________________________
____________________________________
City
State
ZIP Code
_________
_________
_________
$_________________ $__________________
Mortgage
Car
Credit card
Loan repayment
Suppliers or vendors
Other ____________
Case 3:23-cr-00003-DHB-BKE Document 19-1 Filed 08/31/23 Page 3 of 12

Debtor 1
_______________________________________________________
Case number (if known)_____________________________________
First Name
Middle Name
Last Name
2IILFLDO)RUP
Statement of Financial Affairs for Individuals Filing for Bankruptcy
page 4
7. Within 1 year before you filed for bankruptcy, did you make a payment on a debt you owed anyone who was an insider?
Insiders include your relatives; any general partners; relatives of any general partners; partnerships of which you are a general partner;
corporations of which you are an officer, director, person in control, or owner of 20% or more of their voting securities; and any managing
agent, including one for a business you operate as a sole proprietor. 11 U.S.C. § 101. Include payments for domestic support obligations,
such as child support and alimony.
No
Yes. List all payments to an insider.
____________________________________________
Insider’s Name
____________________________________________
Number
Street
____________________________________________
____________________________________________
City
State
ZIP Code
Dates of
payment
Total amount
paid
Amount you still
owe
Reason for this payment
_________
_________
_________
$____________ $____________
____________________________________________
Insider’s Name
____________________________________________
Number
Street
____________________________________________
____________________________________________
City
State
ZIP Code
_________
_________
_________
$____________ $____________
8. Within 1 year before you filed for bankruptcy, did you make any payments or transfer any property on account of a debt that benefited
an insider?
Include payments on debts guaranteed or cosigned by an insider.
No
Yes. List all payments that benefited an insider.
____________________________________________
Insider’s Name
____________________________________________
Number
Street
____________________________________________
____________________________________________
City
State
ZIP Code
Dates of
payment
Total amount
paid
Amount you still
owe
Reason for this payment
Include creditor’s name
_________
_________
_________
$____________ $____________
____________________________________________
Insider’s Name
____________________________________________
Number
Street
____________________________________________
____________________________________________
City
State
ZIP Code
_________
_________
_________
$____________ $____________
Case 3:23-cr-00003-DHB-BKE Document 19-1 Filed 08/31/23 Page 4 of 12

Property was repossessed.

Property was foreclosed.

Property was garnished.

Property was attached, seized, or levied.
_________________________________________
Creditor’s Name
_________________________________________
Number
Street
_________________________________________
_________________________________________
City
State
ZIP Code
Describe the property
Date
Value of the property
__________
$______________
Explain what happened

Property was repossessed.

Property was foreclosed.

Property was garnished.

Property was attached, seized, or levied.
Case 3:23-cr-00003-DHB-BKE Document 19-1 Filed 08/31/23 Page 5 of 12

Debtor 1
_______________________________________________________
Case number (if known)_____________________________________
First Name
Middle Name
Last Name
2IILFLDO)RUP
Statement of Financial Affairs for Individuals Filing for Bankruptcy
page 8
____________________________________
Person Who Was Paid
____________________________________
Number
Street
____________________________________
____________________________________
City
State
ZIP Code
________________________________________________
Email or website address
Description and value of any property transferred
Date payment or
transfer was made
Amount of
payment
_________
_________
$_____________
$_____________
___________________________________
Person Who Made the Payment, if Not You
17. Within 1 year before you filed for bankruptcy, did you or anyone else acting on your behalf pay or transfer any property to anyone who
promised to help you deal with your creditors or to make payments to your creditors?
Do not include any payment or transfer that you listed on line 16.
No
Yes. Fill in the details.
____________________________________
Person Who Was Paid
____________________________________
Number
Street
____________________________________
____________________________________
City
State
ZIP Code
Description and value of any property transferred
Date payment or
transfer was
made
Amount of payment
_________
_________
$____________
$____________
18. Within 2 years before you filed for bankruptcy, did you sell, trade, or otherwise transfer any property to anyone, other than property
transferred in the ordinary course of your business or financial affairs?
Include both outright transfers and transfers made as security (such as the granting of a security interest or mortgage on your property).
Do not include gifts and transfers that you have already listed on this statement.
No
Yes. Fill in the details.
___________________________________
Person Who Received Transfer
___________________________________
Number
Street
___________________________________
___________________________________
City
State
ZIP Code
Description and value of property
transferred
Describe any property or payments received
or debts paid in exchange
Date transfer
was made
_________
Person’s relationship to you _____________
___________________________________
Person Who Received Transfer
___________________________________
Number
Street
___________________________________
___________________________________
City
State
ZIP Code
_________
Person’s relationship to you _____________
Case 3:23-cr-00003-DHB-BKE Document 19-1 Filed 08/31/23 Page 8 of 12

Checking
Savings
Money market
Brokerage
Other__________
_________
$___________
____________________________________
Name of Financial Institution
____________________________________
Number
Street
____________________________________
____________________________________
City
State
ZIP Code
XXXX–___ ___ ___ ___

Checking
Savings
Money market
Brokerage
Other__________
_________
$___________
21. Do you now have, or did you have within 1 year before you filed for bankruptcy, any safe deposit box or other depository for
securities, cash, or other valuables?
No
Yes. Fill in the details.
____________________________________
Name of Financial Institution
____________________________________
Number
Street
____________________________________
____________________________________
City
State
ZIP Code
Who else had access to it?
Describe the contents
Do you still
have it?
_______________________________________
Name
_______________________________________
Number
Street
_______________________________________
City
State
ZIP Code
No
Yes

Case 3:23-cr-00003-DHB-BKE Document 19-1 Filed 08/31/23 Page 9 of 12

Part 9:
Identify Property You Hold or Control for Someone Else
23. Do you hold or control any property that someone else owns? Include any property you borrowed from, are storing for,
or hold in trust for someone.
No
Yes. Fill in the details.
___________________________________
Owner’s Name
___________________________________
Number
Street
___________________________________
___________________________________
City
State
ZIP Code
Where is the property?
Describe the property
Value
_________________________________________
Number
Street
_________________________________________
_________________________________________
City
State
ZIP Code
$__________
Part 10:
Give Details About Environmental Information
For the purpose of Part 10, the following definitions apply:

Environmental law means any federal, state, or local statute or regulation concerning pollution, contamination, releases of
hazardous or toxic substances, wastes, or material into the air, land, soil, surface water, groundwater, or other medium,
including statutes or regulations controlling the cleanup of these substances, wastes, or material.

Site means any location, facility, or property as defined under any environmental law, whether you now own, operate, or
utilize it or used to own, operate, or utilize it, including disposal sites.

Hazardous material means anything an environmental law defines as a hazardous waste, hazardous substance, toxic
substance, hazardous material, pollutant, contaminant, or similar term.
Report all notices, releases, and proceedings that you know about, regardless of when they occurred.
24. Has any governmental unit notified you that you may be liable or potentially liable under or in violation of an environmental law?
No
Yes. Fill in the details.
____________________________________
Name of site
____________________________________
Number
Street
____________________________________
____________________________________
City
State
ZIP Code
Governmental unit
Environmental law, if you know it
Date of notice
_______________________________
Governmental unit
_______________________________
Number
Street
_______________________________
City
State
ZIP Code
_________
Case 3:23-cr-00003-DHB-BKE Document 19-1 Filed 08/31/23 Page 10 of 12

Concluded

Part 11:
Give Details About Your Business or Connections to Any Business
27. Within 4 years before you filed for bankruptcy, did you own a business or have any of the following connections to any business?
A sole proprietor or self-employed in a trade, profession, or other activity, either full-time or part-time
A member of a limited liability company (LLC) or limited liability partnership (LLP)
A partner in a partnership
An officer, director, or managing executive of a corporation
An owner of at least 5% of the voting or equity securities of a corporation
No. None of the above applies. Go to Part 12.
Yes. Check all that apply above and fill in the details below for each business.
____________________________________
Business Name
____________________________________
Number
Street
____________________________________
____________________________________
City
State
ZIP Code
Describe the nature of the business
Employer Identification number
Do not include Social Security number or ITIN.
EIN: ___ ___ – ___ ___ ___ ___ ___ ___ ___
Name of accountant or bookkeeper
Dates business existed
From _______ To _______
____________________________________
Business Name
____________________________________
Number
Street
____________________________________
____________________________________
City
State
ZIP Code
Describe the nature of the business
Employer Identification number
Do not include Social Security number or ITIN.
EIN: ___ ___ – ___ ___ ___ ___ ___ ___ ___
Name of accountant or bookkeeper
Dates business existed
From _______ To _______
Case 3:23-cr-00003-DHB-BKE Document 19-1 Filed 08/31/23 Page 11 of 12

Debtor 1
_______________________________________________________
Case number (if known)_____________________________________
First Name
Middle Name
Last Name
2IILFLDO)RUP
Statement of Financial Affairs for Individuals Filing for Bankruptcy
page 12
____________________________________
Business Name
____________________________________
Number
Street
____________________________________
____________________________________
City
State
ZIP Code
Describe the nature of the business
Employer Identification number
Do not include Social Security number or ITIN.
EIN: ___ ___ – ___ ___ ___ ___ ___ ___ ___
Name of accountant or bookkeeper
Dates business existed
From _______ To _______
28. Within 2 years before you filed for bankruptcy, did you give a financial statement to anyone about your business? Include all financial
institutions, creditors, or other parties.
No
Yes. Fill in the details below.
____________________________________
Name
____________________________________
Number
Street
____________________________________
____________________________________
City
State
ZIP Code
Date issued
____________
MM / DD / YYYY
Part 12:
Sign Below
I have read the answers on this Statement of Financial Affairs and any attachments, and I declare under penalty of perjury that the
answers are true and correct. I understand that 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.
8______________________________________________ 8_____________________________
Signature of Debtor 1
Signature of Debtor 2
Date ________________
Date _________________
Did you attach additional pages to Your Statement of Financial Affairs for Individuals Filing for Bankruptcy (Official Form 107)?

Yes
Did you pay or agree to pay someone who is not an attorney to help you fill out bankruptcy forms?
No
Yes. Name of person_____________________________________________________________. Attach the Bankruptcy Petition Preparer’s Notice,
Declaration, and Signature (Official Form 119).
Case 3:23-cr-00003-DHB-BKE Document 19-1 Filed 08/31/23 Page 12 of 12

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Form 107 — USA v. Harun (Dkt. 19.1)

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