Form 106E — USA v. Harun (Dkt. 19.4)

Record facts

U.S. District Court for the Southern District of Georgia · No. 3:23-cr-00003-DHB-BKE · Doc. 19-4 · 2023-08-31 · Docket on CourtListener

Full text

Official Form 106E/F
Schedule E/F: Creditors Who Have Unsecured Claims
page 1 of ___ 
2IILFLDO)RUP106E/F
Schedule E/F: Creditors Who Have Unsecured Claims
12/15
Be as complete and accurate as possible. Use Part 1 for creditors with PRIORITY claims and Part 2 for creditors with NONPRIORITY claims. 
List the other party to any executory contracts or unexpired leases that could result in a claim.  Also list executory contracts on Schedule
A/B: Property (Official Form 106A/B) and on Schedule G: Executory Contracts and Unexpired Leases (Official Form 106G). Do not include any 
creditors with partially secured claims that are listed in Schedule D: Creditors Who Have Claims Secured by Property. If more space is 
needed, copy the Part you need, fill it out, number the entries in the boxes on the left. Attach the Continuation Page to this page. On the top of 
any additional pages, write your name and case number (if known).  
Part 1:  List All of Your PRIORITY Unsecured Claims 
1. Do any creditors have priority unsecured claims against you?
‰ No. Go to Part 2.
‰ Yes.
2.
List all of your priority unsecured claims. If a creditor has more than one priority unsecured claim, list the creditor separately for each claim. For
each claim listed, identify what type of claim it is. If a claim has both priority and nonpriority amounts, list that claim here and show both priority and
nonpriority amounts. As much as possible, list the claims in alphabetical order according to the creditor’s name. If you have more than two priority
unsecured claims, fill out the Continuation Page of Part 1. If more than one creditor holds a particular claim, list the other creditors in Part 3.
(For an explanation of each type of claim, see the instructions for this form in the instruction booklet.)
Total claim 
Priority 
amount 
Nonpriority 
amount
2.1
____________________________________________ 
Priority Creditor’s Name 
____________________________________________ 
Number 
Street 
____________________________________________ 
____________________________________________ 
City 
State 
ZIP Code
Last 4 digits of account number  ___  ___  ___  ___
$_____________ $___________ $____________
When was the debt incurred?  
____________
As of the date you file, the claim is: Check all that apply.
‰ Contingent 
‰ Unliquidated 
‰ Disputed 
Type of PRIORITY unsecured claim:
‰ Domestic support obligations 
‰ Taxes and certain other debts you owe the government 
‰ Claims for death or personal injury while you were 
intoxicated 
‰ Other. Specify _________________________________
Who incurred the debt? Check one. 
‰ Debtor 1 only 
‰ Debtor 2 only 
‰ Debtor 1 and Debtor 2 only 
‰ At least one of the debtors and another
‰ Check if this claim is for a community debt
Is the claim subject to offset?
‰ No
‰ Yes
2.2
____________________________________________ 
Priority Creditor’s Name 
____________________________________________ 
Number 
Street 
____________________________________________ 
____________________________________________ 
City 
State 
ZIP Code
Who incurred the debt? Check one. 
‰ Debtor 1 only 
‰ Debtor 2 only 
‰ Debtor 1 and Debtor 2 only 
‰ At least one of the debtors and another
‰ Check if this claim is for a community debt
Is the claim subject to offset?
‰ No
‰ Yes
Last 4 digits of account number  ___  ___  ___  ___ 
When was the debt incurred?  
____________ 
As of the date you file, the claim is: Check all that apply.
‰ Contingent 
‰ Unliquidated 
‰ Disputed 
Type of PRIORITY unsecured claim:
‰ Domestic support obligations 
‰ Taxes and certain other debts you owe the government 
‰ Claims for death or personal injury while you were 
intoxicated 
‰ Other. Specify _________________________________
$_____________ $___________ $____________
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 19-4     Filed 08/31/23     Page 1 of 6

Debtor 1 
_______________________________________________________ 
Case number (if known)_____________________________________  
First Name 
Middle Name 
Last Name
2IILFLDO)RUP()
Schedule E/F: Creditors Who Have Unsecured Claims
page __ of ___ 
Part 1:  
Your PRIORITY Unsecured Claims Ʌ Continuation Page 
After listing any entries on this page, number them beginning with 2.3, followed by 2.4, and so forth.
Total claim 
Priority 
amount 
Nonpriority 
amount
____________________________________________ 
Priority Creditor’s Name 
____________________________________________ 
Number 
Street 
____________________________________________ 
____________________________________________ 
City 
State 
ZIP Code
Who incurred the debt? Check one. 
‰ Debtor 1 only 
‰ Debtor 2 only 
‰ Debtor 1 and Debtor 2 only 
‰ At least one of the debtors and another
‰ Check if this claim is for a community debt
Is the claim subject to offset?
‰ No
‰ Yes
Last 4 digits of account number  ___  ___  ___  ___ 
When was the debt incurred?  
____________ 
As of the date you file, the claim is: Check all that apply.  
‰ Contingent 
‰ Unliquidated 
‰ Disputed 
Type of PRIORITY unsecured claim:
‰ Domestic support obligations 
‰ Taxes and certain other debts you owe the government 
‰ Claims for death or personal injury while you were 
intoxicated 
‰ Other. Specify _________________________________
$____________ $__________ $____________
____________________________________________ 
Priority Creditor’s Name 
____________________________________________ 
Number 
Street 
____________________________________________ 
____________________________________________ 
City 
State 
ZIP Code
Who incurred the debt? Check one. 
‰ Debtor 1 only 
‰ Debtor 2 only 
‰ Debtor 1 and Debtor 2 only 
‰ At least one of the debtors and another
‰ Check if this claim is for a community debt
Is the claim subject to offset?
‰ No
‰ Yes
Last 4 digits of account number  ___  ___  ___  ___ 
When was the debt incurred?  
____________ 
As of the date you file, the claim is: Check all that apply.  
‰ Contingent 
‰ Unliquidated 
‰ Disputed 
Type of PRIORITY unsecured claim:
‰ Domestic support obligations 
‰ Taxes and certain other debts you owe the government 
‰ Claims for death or personal injury while you were 
intoxicated 
‰ Other. Specify _________________________________
$____________ $__________ $____________
____________________________________________ 
Priority Creditor’s Name 
____________________________________________ 
Number 
Street 
____________________________________________ 
____________________________________________ 
City 
State 
ZIP Code
Who incurred the debt? Check one. 
‰ Debtor 1 only 
‰ Debtor 2 only 
‰ Debtor 1 and Debtor 2 only 
‰ At least one of the debtors and another
‰ Check if this claim is for a community debt
Is the claim subject to offset?
‰ No
‰ Yes
Last 4 digits of account number  ___  ___  ___  ___ 
When was the debt incurred?  
____________ 
As of the date you file, the claim is: Check all that apply.  
‰ Contingent 
‰ Unliquidated 
‰ Disputed 
Type of PRIORITY unsecured claim:
‰ Domestic support obligations 
‰ Taxes and certain other debts you owe the government 
‰ Claims for death or personal injury while you were 
intoxicated 
‰ Other. Specify _________________________________
$____________ $__________ $____________
Case 3:23-cr-00003-DHB-BKE     Document 19-4     Filed 08/31/23     Page 2 of 6

Debtor 1 
_______________________________________________________ 
Case number (if known)_____________________________________  
First Name 
Middle Name 
Last Name
2IILFLDO)RUP()
Schedule E/F: Creditors Who Have Unsecured Claims
page __ of ___ 
Part 2:  List All of Your NONPRIORITY Unsecured Claims 
3. Do any creditors have nonpriority unsecured claims against you?
‰ No. You have nothing to report in this part. Submit this form to the court with your other schedules.
‰ Yes
4. List all of your nonpriority unsecured claims in the alphabetical order of the creditor who holds each claim. If a creditor has more than one
nonpriority unsecured claim, list the creditor separately for each claim. For each claim listed, identify what type of claim it is. Do not list claims already
included in Part 1. If more than one creditor holds a particular claim, list the other creditors in Part 3.If you have more than three nonpriority unsecured
claims fill out the Continuation Page of Part 2.
Total claim
4.1 
_____________________________________________________________ 
Nonpriority Creditor’s Name 
_____________________________________________________________ 
Number 
Street 
_____________________________________________________________ 
City 
State 
ZIP Code
Last 4 digits of account number ___  ___  ___  ___
$__________________
When was the debt incurred?  
____________
As of the date you file, the claim is: Check all that apply.  
‰ Contingent 
‰ Unliquidated 
‰ Disputed 
Type of NONPRIORITY unsecured claim:
‰ Student loans
‰ Obligations arising out of a separation agreement or divorce 
that you did not report as priority claims
‰ Debts to pension or profit-sharing plans, and other similar debts
‰ Other. Specify ______________________________________
Who incurred the debt? Check one. 
‰ Debtor 1 only 
‰ Debtor 2 only 
‰ Debtor 1 and Debtor 2 only 
‰ At least one of the debtors and another
‰ Check if this claim is for a community debt
Is the claim subject to offset?
‰ No
‰ Yes
4.2
_____________________________________________________________ 
Nonpriority Creditor’s Name 
_____________________________________________________________ 
Number 
Street 
_____________________________________________________________ 
City 
State 
ZIP Code
Last 4 digits of account number  ___  ___  ___  ___
$__________________
When was the debt incurred? 
____________
As of the date you file, the claim is: Check all that apply.  
‰ Contingent 
‰ Unliquidated 
‰ Disputed 
Type of NONPRIORITY unsecured claim:
‰ Student loans
‰ Obligations arising out of a separation agreement or divorce 
that you did not report as priority claims
‰ Debts to pension or profit-sharing plans, and other similar debts
‰ Other. Specify ______________________________________
Who incurred the debt? Check one. 
‰ Debtor 1 only 
‰ Debtor 2 only 
‰ Debtor 1 and Debtor 2 only 
‰ At least one of the debtors and another
‰ Check if this claim is for a community debt
Is the claim subject to offset?
‰ No
‰ Yes
4.3 
_____________________________________________________________ 
Nonpriority Creditor’s Name 
_____________________________________________________________ 
Number 
Street 
_____________________________________________________________ 
City 
State 
ZIP Code
Last 4 digits of account number  ___  ___  ___  ___
$_________________ 
When was the debt incurred? 
____________
As of the date you file, the claim is: Check all that apply.  
‰ Contingent 
‰ Unliquidated 
‰ Disputed 
Type of NONPRIORITY unsecured claim:
‰ Student loans
‰ Obligations arising out of a separation agreement or divorce 
that you did not report as priority claims
‰ Debts to pension or profit-sharing plans, and other similar debts
‰ Other. Specify ______________________________________
Who incurred the debt? Check one. 
‰ Debtor 1 only 
‰ Debtor 2 only 
‰ Debtor 1 and Debtor 2 only 
‰ At least one of the debtors and another
‰ Check if this claim is for a community debt
Is the claim subject to offset?
‰ No
‰ Yes
Case 3:23-cr-00003-DHB-BKE     Document 19-4     Filed 08/31/23     Page 3 of 6

Debtor 1 
_______________________________________________________ 
Case number (if known)_____________________________________  
First Name 
Middle Name 
Last Name
2IILFLDO)RUP()
Schedule E/F: Creditors Who Have Unsecured Claims
page __ of ___ 
Part 2:  Your NONPRIORITY Unsecured Claims Ʌ Continuation Page 
After listing any entries on this page, number them beginning with 4.4, followed by 4.5, and so forth.
Total claim
_____________________________________________________________ 
Nonpriority Creditor’s Name 
_____________________________________________________________ 
Number 
Street 
_____________________________________________________________ 
City 
State 
ZIP Code
Who incurred the debt? Check one. 
‰ Debtor 1 only 
‰ Debtor 2 only 
‰ Debtor 1 and Debtor 2 only 
‰ At least one of the debtors and another
‰ Check if this claim is for a community debt
Is the claim subject to offset?
‰ No
‰ Yes
Last 4 digits of account number  ___  ___  ___  ___ 
When was the debt incurred?  
____________ 
As of the date you file, the claim is: Check all that apply.  
‰ Contingent 
‰ Unliquidated 
‰ Disputed 
Type of NONPRIORITY unsecured claim:
‰ Student loans
‰ Obligations arising out of a separation agreement or divorce that
you did not report as priority claims 
‰ Debts to pension or profit-sharing plans, and other similar debts 
‰ Other. Specify________________________________
$____________
_____________________________________________________________ 
Nonpriority Creditor’s Name 
_____________________________________________________________ 
Number 
Street 
_____________________________________________________________ 
City 
State 
ZIP Code
Who incurred the debt? Check one. 
‰ Debtor 1 only 
‰ Debtor 2 only 
‰ Debtor 1 and Debtor 2 only 
‰ At least one of the debtors and another
‰ Check if this claim is for a community debt
Is the claim subject to offset?
‰ No
‰ Yes
Last 4 digits of account number  ___  ___  ___  ___ 
When was the debt incurred?  
____________ 
As of the date you file, the claim is: Check all that apply.  
‰ Contingent 
‰ Unliquidated 
‰ Disputed 
Type of NONPRIORITY unsecured claim:
‰ Student loans
‰ Obligations arising out of a separation agreement or divorce that
you did not report as priority claims 
‰ Debts to pension or profit-sharing plans, and other similar debts 
‰ Other. Specify________________________________
$____________
_____________________________________________________________ 
Nonpriority Creditor’s Name 
_____________________________________________________________ 
Number 
Street 
_____________________________________________________________ 
City 
State 
ZIP Code
Who incurred the debt? Check one. 
‰ Debtor 1 only 
‰ Debtor 2 only 
‰ Debtor 1 and Debtor 2 only 
‰ At least one of the debtors and another
‰ Check if this claim is for a community debt
Is the claim subject to offset?
‰ No
‰ Yes
Last 4 digits of account number  ___  ___  ___  ___ 
When was the debt incurred?  
____________ 
As of the date you file, the claim is: Check all that apply.  
‰ Contingent 
‰ Unliquidated 
‰ Disputed 
Type of NONPRIORITY unsecured claim:
‰ Student loans
‰ Obligations arising out of a separation agreement or divorce that
you did not report as priority claims 
‰ Debts to pension or profit-sharing plans, and other similar debts 
‰ Other. Specify________________________________
$____________
Case 3:23-cr-00003-DHB-BKE     Document 19-4     Filed 08/31/23     Page 4 of 6

Debtor 1 
_______________________________________________________ 
Case number (if known)_____________________________________  
First Name 
Middle Name 
Last Name
2IILFLDO)RUP()
Schedule E/F: Creditors Who Have Unsecured Claims
page __ of ___ 
Part 3:  List Others to Be Notified About a Debt That You Already Listed 
5. Use this page only if you have others to be notified about your bankruptcy, for a debt that you already listed in Parts 1 or 2. For
example, if a collection agency is trying to collect from you for a debt you owe to someone else, list the original creditor in Parts 1 or
2, then list the collection agency here. Similarly, if you have more than one creditor for any of the debts that you listed in Parts 1 or 2, list the
additional creditors here. If you do not have additional persons to be notified for any debts in Parts 1 or 2, do not fill out or submit this page.
_____________________________________________________ 
Name 
_____________________________________________________ 
Number 
Street 
_____________________________________________________ 
_____________________________________________________ 
City 
State 
ZIP Code
On which entry in Part 1 or Part 2 did you list the original creditor? 
Line _____ of  (Check one): ‰ Part 1: Creditors with Priority Unsecured Claims 
‰ Part 2: Creditors with Nonpriority Unsecured Claims
Last 4 digits of account number ___  ___  ___  ___
_____________________________________________________ 
Name 
_____________________________________________________ 
Number 
Street 
_____________________________________________________ 
_____________________________________________________ 
City 
State 
ZIP Code
On which entry in Part 1 or Part 2 did you list the original creditor? 
Line _____ of  (Check one): ‰ Part 1: Creditors with Priority Unsecured Claims 
‰ Part 2: Creditors with Nonpriority Unsecured
Claims
Last 4 digits of account number ___  ___  ___  ___
_____________________________________________________ 
Name 
_____________________________________________________ 
Number 
Street 
_____________________________________________________ 
_____________________________________________________ 
City 
State 
ZIP Code
On which entry in Part 1 or Part 2 did you list the original creditor? 
Line _____ of  (Check one): ‰ Part 1: Creditors with Priority Unsecured Claims 
‰ Part 2: Creditors with Nonpriority Unsecured
Claims
Last 4 digits of account number ___  ___  ___  ___
_____________________________________________________ 
Name 
_____________________________________________________ 
Number 
Street 
_____________________________________________________ 
_____________________________________________________ 
City 
State 
ZIP Code
On which entry in Part 1 or Part 2 did you list the original creditor? 
Line _____ of  (Check one): ‰ Part 1: Creditors with Priority Unsecured Claims 
‰ Part 2: Creditors with Nonpriority Unsecured
Claims
Last 4 digits of account number ___  ___  ___  ___
_____________________________________________________ 
Name 
_____________________________________________________ 
Number 
Street 
_____________________________________________________ 
_____________________________________________________ 
City 
State 
ZIP Code
On which entry in Part 1 or Part 2 did you list the original creditor? 
Line _____ of  (Check one): ‰ Part 1: Creditors with Priority Unsecured Claims 
‰ Part 2: Creditors with Nonpriority Unsecured
Claims
Last 4 digits of account number ___  ___  ___  ___
_____________________________________________________ 
Name 
_____________________________________________________ 
Number 
Street 
_____________________________________________________ 
_____________________________________________________ 
City 
State 
ZIP Code
On which entry in Part 1 or Part 2 did you list the original creditor? 
Line _____ of  (Check one): ‰ Part 1: Creditors with Priority Unsecured Claims 
‰ Part 2: Creditors with Nonpriority Unsecured
Claims
Last 4 digits of account number ___  ___  ___  ___
_____________________________________________________ 
Name 
_____________________________________________________ 
Number 
Street 
_____________________________________________________ 
_____________________________________________________ 
City 
State 
ZIP Code
On which entry in Part 1 or Part 2 did you list the original creditor? 
Line _____ of  (Check one): ‰ Part 1: Creditors with Priority Unsecured Claims 
‰ Part 2: Creditors with Nonpriority Unsecured
Claims
Last 4 digits of account number ___  ___  ___  ___
Case 3:23-cr-00003-DHB-BKE     Document 19-4     Filed 08/31/23     Page 5 of 6

Debtor 1 
_______________________________________________________ 
Case number (if known)_____________________________________  
First Name 
Middle Name 
Last Name
2IILFLDO)RUP()
Schedule E/F: Creditors Who Have Unsecured Claims
page __ of ___ 
Part 4: 
Add the Amounts for Each Type of Unsecured Claim
6. Total the amounts of certain types of unsecured claims. This information is for statistical reporting purposes only. 28 U.S.C. § 159.
Add the amounts for each type of unsecured claim.
Total claim 
Total claims 
from Part 1
6a. Domestic support obligations 
6a.
 
$_________________________ 
6b. Taxes and certain other debts you owe the 
government 
6b.
 
$_________________________ 
6c. Claims for death or personal injury while you were 
intoxicated
6c.
$_________________________ 
 
6d. Other. Add all other priority unsecured claims. 
Write that amount here. 
6d. + $_________________________ 
6e. Total. Add lines 6a through 6d.
6e.
 
$_________________________ 
Total claim 
Total claims 
from Part 2
6f. Student loans 
6f.
 
$_________________________ 
6g. Obligations arising out of a separation agreement 
or divorce that you did not report as priority 
claims 
6g.
 
$_________________________ 
6h. Debts to pension or profit-sharing plans, and other 
similar debts 
6h.
$_________________________ 
6i. Other. Add all other nonpriority unsecured claims.  
 
Write that amount here. 
6i. + $_________________________
6j. Total. Add lines 6f through 6i. 
6j.
 
$_________________________ 
Case 3:23-cr-00003-DHB-BKE     Document 19-4     Filed 08/31/23     Page 6 of 6

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