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B1 (Official Form 1) (12/11)

Case 13-60797-fra7 Doc 1 Filed 03/14/13

United States Bankruptcy Court

District of Oregon

Voluntary Petition

Name of Debtor (if individual, enter Last, First, Middle):
Aipia, Kelii Kaimi Nuhi
All Other Names used by the Debtor in the last 8 years
(include married, maiden, and trade names):
None

Name of Joint Debtor (Spouse) (Last, First, Middle):
Aipia, Melyssa Jan Marie
All Other Names used by the Joint Debtor in the last 8 years
(include married, maiden, and trade names):
None

Last four digits of Soc. Sec. or Individual-Taxpayer I.D. (ITIN) No./Complete EIN
(if more than one, state all):

5343

Last four digits of Soc. Sec. or Individual-Taxpayer I.D. (ITIN) No./Complete EIN
(if more than one, state all):

2100

Street Address of Debtor (No. and Street, City, and State)
6112 Main Street, #4
Springfield, OR

Street Address of Joint Debtor (No. and Street, City, and State
5819 Aster Street, #2
Springfield, OR

County of Residence or of the Principal Place of Business:
Lane
Mailing Address of Debtor (if different from street address):

County of Residence or of the Principal Place of Business:
Lane
Mailing Address of Joint Debtor (if different from street address):

ZIPCODE
97478

ZIPCODE
97478

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

ZIPCODE

ZIPCODE

ZIPCODE

Type of Debtor

(Form of Organization)

(Check one box)

Individual (includes Joint Debtors)
See Exhibit D on page 2 of this form.
Corporation (includes LLC and LLP)
Partnership
Other (If debtor is not one of the above entities,
check this box and state type of entity below.)

Chapter 15 Debtors

Country of debtor’s center of main interests:

Each country in which a foreign proceeding by,
regarding, or against debtor is pending:

Filing Fee (Check one box)

Full Filing Fee attached

Nature of Business

(Check one box)

Health Care Business
Single Asset Real Estate as defined in
11 U.S.C. § 101 (51B)
Railroad
Stockbroker
Commodity Broker
Clearing Bank
N.A.
Other

Tax-Exempt Entity

(Check box, if applicable)

Debtor is a tax-exempt organization
under Title 26 of the United States
Code (the Internal Revenue Code)

Chapter of Bankruptcy Code Under Which

Chapter 7
Chapter 9
Chapter 11
Chapter 12
Chapter 13

the Petition is Filed (Check one box)
Chapter 15 Petition for
Recognition of a Foreign
Main Proceeding
Chapter 15 Petition for
Recognition of a Foreign
Nonmain Proceeding

Nature of Debts
(Check one box)

Debts are primarily consumer
debts, defined in 11 U.S.C.
§101(8) as "incurred by an
individual primarily for a
personal, family, or
household purpose."

Debts are
primarily
business debts.

Check one box:

Chapter 11 Debtors

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

Filing Fee to be paid in installments (applicable to individuals only) Must attach
signed 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.

Filing Fee waiver requested (applicable to chapter 7 individuals only). Must
attach signed application for the court’s consideration. See Official Form 3B.

Check if:

Debtor’s aggregate noncontingent liquidated debts (excluding debts owed to
insiders or affiliates) are less than $2,343,300 (amount subject to adjustment on
4/01/13 and every three years thereafter).

Check all applicable boxes

A plan is being filed with this petition.
Acceptances of the plan were solicited prepetition from one or more
classes of 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 expenses paid, there will be no funds available for
distribution to unsecured creditors.

Estimated Number of Creditors

THIS SPACE IS FOR
COURT USE ONLY

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

Over
100,000

Estimated Assets

$0 to
$50,000

$50,001 to
$100,000

$100,001 to
$500,000

Estimated Liabilities

$500,001
to $1
million

$1,000,001
to $10
million

$10,000,001
to $50
million

$50,000,001
to $100
million

$100,000,001
to $500
million

$500,000,001
to $1 billion

More than
$1 billion

$0 to
$50,000

$50,001 to
$100,000

$100,001 to
$500,000

$500,001
to $1
million

$1,000,001
to $10
million

$10,000,001
to $50
million

$50,000,001
to $100
million

$100,000,001
to $500
million

$500,000,001
to $1 billion

More than
$1 billion

B1 (Official Form 1) (12/11)
Voluntary Petition
(This page must be completed and filed in every case)

Name of Debtor(s):
Kelii Kaimi Nuhi Aipia & Melyssa Jan Marie Aipia

Case 13-60797-fra7 Doc 1 Filed 03/14/13

Page 2

Location
Where Filed:

Location
Where Filed:

All Prior Bankruptcy Cases Filed Within Last 8 Years (If more than two, attach additional sheet)
NONE

Case Number:

N.A.

Case Number:

Date Filed:

Date Filed:

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

NONE

Name of Debtor:

District:

Exhibit A

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

Case Number:

Relationship:

Date Filed:

Judge:

Exhibit B

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

I, the attorney for the petitioner named in the foregoing petition, declare that I
have informed the petitioner that [he or she] may proceed under chapter 7, 11,
12, or 13 of title 11, United States Code, and have explained the relief
available under each such chapter.
I further certify that I delivered to the
debtor the notice required by 11 U.S.C. § 342(b).

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

X

/s/ K. Sam Knudsen

2-6-13
Signature of Attorney for Debtor(s) Date

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

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

No.

(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.

Exhibit D

Information Regarding the Debtor - Venue

(Check any applicable box)

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.

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

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

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

(Check all applicable boxes)

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

(Name of landlord that obtained judgment)

(Address of landlord)

Debtor claims that under applicable nonbankruptcy law, there are circumstances under which the debtor would be permitted to cure the
entire monetary default that gave rise to the judgment for possession, after the judgment for possession was entered, and
Debtor has included in this petition the deposit with the court of any rent that would become due during the 30-day period after the
filing of the petition.
Debtor certifies that he/she has served the Landlord with this certification. (11 U.S.C. § 362(1)).

Case 13-60797-fra7 Doc 1 Filed 03/14/13

B1 (Official Form 1) (12/11)
Voluntary Petition
(This page must be completed and filed in every case)

Name of Debtor(s):
Kelii Kaimi Nuhi Aipia & Melyssa Jan Marie Aipia

Signatures

Page 3

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

Signature of a Foreign Representative

I declare under penalty of perjury that the information provided in this petition
is true and correct.
[If petitioner is an individual whose debts are primarily consumer debts and
has chosen to file under chapter 7] I am aware that I may proceed under
chapter 7, 11, 12, or 13 of title 11, United States Code, understand the relief
available under each such chapter, and choose to proceed under chapter 7.
[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).

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

X

/s/ Kelii Kaimi Nuhi Aipia
Signature of Debtor

X

/s/ Melyssa Jan Marie Aipia
Signature of Joint Debtor

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

(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 11 U.S.C. § 1515 of title 11 are
attached.

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

X

(Signature of Foreign Representative)

(Printed Name of Foreign Representative)

Telephone Number (If not represented by attorney)
2-6-13
Date

(Date)

Signature of Attorney*

Signature of Non-Attorney Petition Preparer

X

/s/ K. Sam Knudsen

Signature of Attorney for Debtor(s)
K. SAM KNUDSEN 86115
Printed Name of Attorney for Debtor(s)
Harder, Wells, Baron & Manning
Firm Name
474 Willamette Street
Address
Eugene, OR 97401

541-686-1969
Telephone Number
2-6-13
Date

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

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

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

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.)

Address

Signature of Debtor (Corporation/Partnership)

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

X

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

X

Signature of Authorized Individual

Printed Name of Authorized Individual

Title of Authorized Individual

Date

Date
Signature of bankruptcy petition preparer or officer, principal, responsible
person, or partner whose Social Security number is provided above.
Names and Social Security numbers of all other individuals who prepared or
assisted in preparing this document unless the bankruptcy petition preparer is
not an individual:

If more than one person prepared this document, attach additional sheets
conforming to the appropriate official form for each person.
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.

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Case 13-60797-fra7 Doc 1 Filed 03/14/13

B1 D (Official Form 1, Exhibit D ) (12/09)

UNITED STATES BANKRUPTCY COURT

District of Oregon

Kelii Kaimi Nuhi Aipia & Melyssa Jan
Marie Aipia

In re______________________________________


Debtor(s)





















Case No._____________

(if known)

EXHIBIT D - INDIVIDUAL DEBTOR'S STATEMENT OF COMPLIANCE WITH

CREDIT COUNSELING REQUIREMENT


Warning: You must be able to check truthfully one of the five statements regarding
credit counseling listed below. If you cannot do so, you are not eligible to file a bankruptcy
case, and the court can dismiss any case you do file. If that happens, you will lose whatever
filing fee you paid, and your creditors will be able to resume 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 file a 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 credit counseling agency approved by the United States trustee or bankruptcy
administrator that outlined the opportunities for available credit counseling and assisted me in
performing a related budget analysis, and I have a certificate from the 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 credit counseling agency approved by the United States trustee or bankruptcy
administrator that outlined the opportunities for available credit counseling and assisted me in
performing a related budget analysis, but I do not have a certificate from the agency describing
the services provided to me. You must file a copy of a certificate from the agency describing the
services provided to you and a copy of any debt repayment plan developed through the agency
no later than 14 days after your bankruptcy case is filed.

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Case 13-60797-fra7 Doc 1 Filed 03/14/13

B1 D (Official Form 1, Exh. D) (12/09) – Cont. Page 2

3. I certify that I requested credit counseling services from an approved agency but

was unable to obtain the services during the seven days from the time I made my request, and the
following exigent circumstances merit a temporary waiver of the credit counseling requirement
so I can file my bankruptcy case now. [Summarize exigent circumstances here.]

If your certification is satisfactory to the court, you must still obtain the credit

counseling briefing within the first 30 days after you file your bankruptcy petition and
promptly file a certificate from the agency that provided the counseling, together with a
copy of any debt management plan developed through the agency. Failure to fulfill these
requirements may result in dismissal of your case. Any extension of the 30-day deadline
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 first receiving a credit counseling briefing.

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

Incapacity. (Defined in 11 U.S.C. § 109(h)(4) as impaired by reason of mental

illness or mental deficiency so as to be incapable of realizing and making rational
decisions with respect to financial responsibilities.);

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

Active military duty in a military combat zone.

5. The United States trustee or bankruptcy administrator has determined that the credit

counseling requirement 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.

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Signature of Debtor:

/s/ Kelii Kaimi Nuhi Aipia
KELII KAIMI NUHI AIPIA

Date: _________________

2-6-13

Case 13-60797-fra7 Doc 1 Filed 03/14/13

B1 D (Official Form 1, Exhibit D ) (12/09)

UNITED STATES BANKRUPTCY COURT

District of Oregon

Kelii Kaimi Nuhi Aipia & Melyssa Jan
Marie Aipia

In re______________________________________


Debtor(s)





















Case No._____________

(if known)

EXHIBIT D - INDIVIDUAL DEBTOR'S STATEMENT OF COMPLIANCE WITH

CREDIT COUNSELING REQUIREMENT


Warning: You must be able to check truthfully one of the five statements regarding
credit counseling listed below. If you cannot do so, you are not eligible to file a bankruptcy
case, and the court can dismiss any case you do file. If that happens, you will lose whatever
filing fee you paid, and your creditors will be able to resume 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 file a 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 credit counseling agency approved by the United States trustee or bankruptcy
administrator that outlined the opportunities for available credit counseling and assisted me in
performing a related budget analysis, and I have a certificate from the 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 credit counseling agency approved by the United States trustee or bankruptcy
administrator that outlined the opportunities for available credit counseling and assisted me in
performing a related budget analysis, but I do not have a certificate from the agency describing
the services provided to me. You must file a copy of a certificate from the agency describing the
services provided to you and a copy of any debt repayment plan developed through the agency
no later than 14 days after your bankruptcy case is filed.

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Case 13-60797-fra7 Doc 1 Filed 03/14/13

B1 D (Official Form 1, Exh. D) (12/09) – Cont. Page 2

3. I certify that I requested credit counseling services from an approved agency but

was unable to obtain the services during the seven days from the time I made my request, and the
following exigent circumstances merit a temporary waiver of the credit counseling requirement
so I can file my bankruptcy case now. [Summarize exigent circumstances here.]

If your certification is satisfactory to the court, you must still obtain the credit

counseling briefing within the first 30 days after you file your bankruptcy petition and
promptly file a certificate from the agency that provided the counseling, together with a
copy of any debt management plan developed through the agency. Failure to fulfill these
requirements may result in dismissal of your case. Any extension of the 30-day deadline
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 first receiving a credit counseling briefing.

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

Incapacity. (Defined in 11 U.S.C. § 109(h)(4) as impaired by reason of mental

illness or mental deficiency so as to be incapable of realizing and making rational
decisions with respect to financial responsibilities.);

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

Active military duty in a military combat zone.

5. The United States trustee or bankruptcy administrator has determined that the credit

counseling requirement 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.

E
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B

Signature of Joint Debtor:

/s/ Melyssa Jan Marie Aipia
MELYSSA JAN MARIE AIPIA

Date: _________________

2-6-13

B203
12/94

Case 13-60797-fra7 Doc 1 Filed 03/14/13

United States Bankruptcy Court

District of Oregon

In re

Kelii Kaimi Nuhi Aipia & Melyssa Jan Marie Aipia

Case No. ____________________
Chapter ____________________

7

Debtor(s)

DISCLOSURE OF COMPENSATION OF ATTORNEY FOR DEBTOR

1. Pursuant to 11 U .S.C. § 329(a) and Fed. Bankr. P. 2016(b), I certify that I am the attorney for the above-named debtor(s)

and that compensation paid to me within one year before the filing of the petition in bankruptcy, or agreed to be paid to me, for services
rendered or to be rendered on behalf of the debtor(s) in contemplation of or in connection with the bankruptcy case is as follow s:

For legal services, I have agreed to accept .............................(cid:171)(cid:171)(cid:171)(cid:171)(cid:171)(cid:171)(cid:171)(cid:171)(cid:171).... $ ______________

Prior to the filing of this statement I have received ..........(cid:171)(cid:171)(cid:171)(cid:171)(cid:171)(cid:171)(cid:171)................... $ ______________

1,194.00
1,194.00
0.00

Balance Due ......................................(cid:171)(cid:171)(cid:171)(cid:171)(cid:171)(cid:171)(cid:171)(cid:171)(cid:171)(cid:171)(cid:171)(cid:171)(cid:171)(cid:171)(cid:171).................... $ ______________

2. The source of compensation paid to me was:

Debtor

Other (specify)

3. The source of compensation to be paid to me is:

Debtor

Other (specify)

4. I have not agreed to share the above-disclosed compensation with any other person unless they are members and
associates of my law firm.

I have agreed to share the above-disclosed compensation with a other person or persons who are not members or associates
of my law firm. A copy of the agreement, together with a list of the names of the people sharing in the compensation, is attached.

5. In return for the above-disclosed fee, I have agreed to render legal service for all aspects of the bankruptcy case, including:

a. Analysis of the debtor's financial situation, and rendering advice to the debtor in determining whether to file a petition in bankruptcy;
b. Preparation and filing of any petition, schedules, statements of affairs and plan which may be required;
c. Representation of the debtor at the meeting of creditors and confirmation hearing, and any adjourned hearings thereof;

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6. By agreement with the debtor(s), the above-disclosed fee does not include the following services:



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I certify that the foregoing is a complete statement of any agreement or arrangement for payment to me for representation of the
debtor(s) in the bankruptcy proceeding.

CERTIFICATION

2-6-13

/s/ K. Sam Knudsen

____________________________________ __________________________________________________

Date Signature of Attorney

__________________________________________________
Name of law firm

Harder, Wells, Baron & Manning

Case 13-60797-fra7 Doc 1 Filed 03/14/13

UNITED STATES BANKRUPTCY COURT

DISTRICT OF OREGON









In re

Kelii Kaimi Nuhi Aipia & Melyssa Jan Marie Aipia


Debtor(s)
*IMPORTANT NOTICES TO DEBTOR(S)














































)
)
)
)
)

Case No. ________________(If Known)

CHAPTER 7 INDIVIDUAL DEBTOR'S*
STATEMENT OF INTENTION
PER 11 U.S.C.

§521(a)





(1) SIGN AND FILE this form even if you show "NONE," AND, if creditors are listed, have the
service certificate COMPLETED; AND
(2) Failure to perform the intentions as to property stated below within 30 days after the first date set for the Meeting of
Creditors under 11 USC §341(a) may result in relief for the creditor from the Automatic Stay protecting such property.

PART A - Debts secured by property of the estate. (Part A must be FULLY COMPLETED for
EACH debt which is secured by property of the estate. Attach additional pages is necessary.)
Property No. 1
Creditor(cid:182)s Name:
Oregon Community Credit Union

2006 Subaru Outback

Describe Property Securing Debt:

Property will be (check one):

SURRENDERED



RETAINED

If retaining the property, I intend to (check at least one):
Redeem the property
Reaffirm the debt
Other. Explain (for example, avoid lien using 11 USC §522(f))

retain, keep current

Property is (check one): CLAIMED AS EXEMPT

NOT CLAIMED AS EXEMPT

Property No. 2 (if necessary)
Creditor(cid:182)s Name:

Describe Property Securing Debt:

Property will be (check one):

SURRENDERED



RETAINED

If retaining the property, I intend to (check at least one):
Redeem the property
Reaffirm the debt
Other. Explain (for example, avoid lien using 11 USC §522(f))

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Property is (check one): CLAIMED AS EXEMPT

NOT CLAIMED AS EXEMPT

Property No. 3 (if necessary)
Creditor(cid:182)s Name:

Describe Property Securing Debt:



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Property will be (check one):

SURRENDERED



RETAINED

If retaining the property, I intend to (check at least one):
Redeem the property
Reaffirm the debt
Other. Explain (for example, avoid lien using 11 USC §522(f))

Property is (check one): CLAIMED AS EXEMPT

NOT CLAIMED AS EXEMPT

521.05 (12/1/08)

Case 13-60797-fra7 Doc 1 Filed 03/14/13

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(cid:182)s Name:






















NO Leased Property







Property No. 2 (if necessary)
Lessor(cid:182)s Name:




































Property No. 3 (if necessary)
Lessor(cid:182)s Name:

























Continuation sheets attached (if any).





































Describe Leased Property:








Lease will be assumed pursuant to
11 USC §365(P)(2):

YES

NO

Describe Leased Property:








Lease will be assumed pursuant to
11 USC §365(P)(2):

YES

NO

Describe Leased Property:








Lease will be assumed pursuant to
11 USC §365(P)(2):

YES

NO























































I DECLARE UNDER PENALTY OF PERJURY THAT THE ABOVE
INDICATES INTENTION AS TO ANY PROPERTY OF MY ESTATE
SECURING A DEBT AND/OR PERSONAL PROPERTY SUBJECT
TO AN UNEXPIRED LEASE.

DATE:

2-6-13

/s/ Kelii Kaimi Nuhi Aipia
DEBTOR(cid:182)S SIGNATURE

/s/ Melyssa Jan Marie Aipia
JOINT DEBTOR(cid:182)S SIGNATURE (if applicable)

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7

.

I /WE THE UNDERSIGNED, CERTIFY THAT COPIES OF BOTH
THIS DOCUMENT AND LOCAL FORM #715 WERE SERVED ON
ANY CREDITOR NAMED ABOVE.

DATE:

2-6-13

/s/ K. Sam Knudsen

86115

DEBTOR OR ATTORNEY(cid:182)S SIGNATURE OSB# (if attorney)

JOINT DEBTOR(cid:182)S SIGNATURE (if applicable and no attorney)

K. SAM KNUDSEN

541-686-1969

PRINT OR TYPE SIGNER(cid:182)S NAME & PHONE NO.

474 Willamette Street

SIGNER(cid:182)S ADDRESS (if attorney)

Eugene, OR 97401

NON-JUDICIAL REMEDY WHEN CONSUMER DEBTOR RAILS TO TIMELY PERFORM STATED INTENTIONS

Creditors, see Local Form #715 [attached if this document was served on paper] if you wish information on how to obtain NON-JUDICIAL
Relief from the automatic stay of 11 U.S.C. §362(a) as to your collateral.

Call an attorney with question about these procedures or the law. However, only call the debtor(cid:182)s attorney if you have questions
About the debtor(cid:182)s intent as to your collateral.

QUESTIONS????

521.05 (12/1/08) Page 2 of

2

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B

Case 13-60797-fra7 Doc 1 Filed 03/14/13

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

United States Bankruptcy Court

District of Oregon

Kelii Kaimi Nuhi Aipia & Melyssa Jan Marie Aipia

In re

Case No.

Debtor

Chapter
SUMMARY OF SCHEDULES

7

Indicate 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
claims from Schedules D, E, and F to determine the total amount of the debtor’s liabilities. Individual debtors must also complete the “Statistical
Summary of Certain Liabilities and Related Data” if they file a case under chapter 7, 11, or 13.

NAME OF SCHEDULE

A – Real Property

B – Personal Property

C – Property Claimed
as exempt

D – Creditors Holding
Secured Claims

E
D
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E - Creditors Holding Unsecured
Priority Claims
(Total of Claims on Schedule E)
F - Creditors Holding Unsecured
Nonpriority Claims

G - Executory Contracts and
Unexpired Leases

H - Codebtors

I - Current Income of
Individual Debtor(s)

J - Current Expenditures of Individual
Debtors(s)

AMOUNTS SCHEDULED

ATTACHED
(YES/NO)

NO. OF SHEETS

ASSETS

LIABILITIES

OTHER

$

$

0.00

9,004.00

$

$

$

5,297.00

0.00

33,326.92

YES

YES

YES

YES

YES

YES

YES

YES

YES

YES

1

3

1

1

2

4

1

1

1

2

$

$

2,855.11

4,672.72

TOTAL

17

$

9,004.00

$

38,623.92

Official Form 6 - Statistical Summary (12/07)

Case 13-60797-fra7 Doc 1 Filed 03/14/13
United States Bankruptcy Court

District of Oregon

In re

Kelii Kaimi Nuhi Aipia & Melyssa Jan Marie Aipia

Case No.

Debtor

Chapter

7

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 any
information here.

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

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

Type of Liability

Amount

Domestic Support Obligations (from Schedule E)

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

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

Student Loan Obligations (from Schedule F)

Domestic Support, Separation Agreement, and Divorce Decree
Obligations Not Reported on Schedule E

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

TOTAL

State the Following:
Average Income (from Schedule I, Line 16)

Average Expenses (from Schedule J, Line 18)

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

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 TO
PRIORITY, 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
0.00

0.00

0.00

0.00

2,855.11

4,672.72

4,412.88

0.00

$

$

$

$

0.00

0.00

33,326.92

33,326.92

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

Case 13-60797-fra7 Doc 1 Filed 03/14/13

In re

Kelii Kaimi Nuhi Aipia & Melyssa Jan Marie Aipia

Debtor

Case No.

(If known)

SCHEDULE A - REAL PROPERTY

Except as directed below, list all real property in which the debtor has any legal, equitable, or future interest, including all property owned as a co-
tenant, community property, or in which the debtor has a life estate. Include any property in which the debtor holds rights and powers exercisable for
the debtor’s own benefit. If the debtor is married, state whether husband, wife, both, or the marital community own the property by placing an “H,”
“W,” “J,” or “C” in the column labeled “Husband, Wife, Joint, or Community.” If the debtor holds no interest in real property, write “None” under
“Description and Location of Property.”

Do not include interests in executory contracts and unexpired leases on this schedule. List them in Schedule G - Executory Contracts and
Unexpired Leases.

If an entity claims to have a lien or hold a secured interest in any property, state the amount of the secured claim. See Schedule D. If no entity
claims to hold a secured interest in the property, write “None” in the column labeled “Amount of Secured Claim.”

If the debtor is an individual or if a joint petition is filed, state the amount of any exemption claimed in the property only in Schedule C –
Property Claimed as Exempt.

I

T
N
O
J

,

E
F
I
W

OF DEBTOR’S
INTEREST IN

Y CURRENT VALUE
T
I
N
U
M
M
O
C
R
O

DEDUCTING ANY
SECURED CLAIM
OR EXEMPTION

PROPERTY, WITHOUT




,

D
N
A
B
S
U
H

AMOUNT OF
SECURED
CLAIM

DESCRIPTION AND LOCATION

OF PROPERTY

NATURE OF DEBTOR’S
INTEREST IN PROPERTY

E
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Total

0.00

(Report also on Summary of Schedules.)

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

Case 13-60797-fra7 Doc 1 Filed 03/14/13

In re

Kelii Kaimi Nuhi Aipia & Melyssa Jan Marie Aipia

Debtor

Case No.

(If known)

SCHEDULE B - PERSONAL PROPERTY

Except as directed below, list all personal property of the debtor of whatever kind. If the debtor has no property in one or more of the categories,
place an “x” in the appropriate position in the column labeled “None.” If additional space is needed in any category, attach a separate sheet properly
identified with the case name, case number, and the number of the category. If the debtor is married, state whether husband, wife, both, or the marital
community own the property by placing an “H,” “W,” “J,” or “C” in the column labeled “Husband, Wife, Joint, or Community.” If the debtor is an
individual or a joint petition is filed, state the amount of any exemptions claimed only in Schedule C - Property Claimed as Exempt.

Do not list interests in executory contracts and unexpired leases on this schedule. List them in Schedule G - Executory Contracts and
Unexpired Leases.

If the property is being held for the debtor by someone else, state that person’s name and address under “Description and Location of Property.”
If the property is being held for a minor child, simply state the child's initials and the name and address of the child's parent or guardian, such as
"A.B., a minor child, by John Doe, guardian." Do not disclose the child's name. See. 11 U.S.C. § 112 and Fed. R. Bankr. P. 1007(m).

TYPE OF PROPERTY

1. Cash on hand.

2. Checking, savings or other financial accounts,
certificates of deposit, or shares in banks, savings
and loan, thrift, building and loan, and homestead
associations, or credit unions, brokerage houses,
or cooperatives.

3. Security deposits with public utilities,
telephone companies, landlords, and others.

4. Household goods and furnishings, including
audio, video, and computer equipment.

N
O
N
E

X

X

DESCRIPTION AND LOCATION

OF PROPERTY

Bank account
Oregon Community Credit Union

Reliacard (child support)
U.S. Bank

Furnishings
Residence

5. Books. Pictures and other art objects,
antiques, stamp, coin, record, tape, compact disc,
and other collections or collectibles.

Books, pictures, dvd's
Residence

E
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5
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6. Wearing apparel.

7. Furs and jewelry.

Clothing
Residence

Jewelry
Residence

8. Firearms and sports, photographic, and other
hobby equipment.

9. Interests in insurance policies. Name
insurance company of each policy and itemize
surrender or refund value of each.

X

X

I

T
N
O
J

,

E
F
I
W


,

D
N
A
B
S
U
H

Y
T
I
N
U
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O
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R
O



CURRENT VALUE OF
DEBTOR’S INTEREST

IN PROPERTY,

WITHOUT

DEDUCTING ANY
SECURED CLAIM
OR EXEMPTION

J

W

J

J

J

J

5.00

206.00

3,000.00

600.00

200.00

500.00

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

Case 13-60797-fra7 Doc 1 Filed 03/14/13

In re

Kelii Kaimi Nuhi Aipia & Melyssa Jan Marie Aipia

Debtor

Case No.

(If known)

SCHEDULE B - PERSONAL PROPERTY

(Continuation Sheet)

N
O
N
E

X
X

X

X

X

X

X

X

X

X

X

X

X

X

TYPE OF PROPERTY

10. Annuities. Itemize and name each issuer.

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

12. Interests in IRA, ERISA, Keogh, or other
pension or profit sharing plans. Give particulars.

13. Stock and interests in incorporated and
unincorporated businesses. Itemize.

14. Interests in partnerships or joint ventures.
Itemize.

15. Government and corporate bonds and other
negotiable and non-negotiable instruments.

16. Accounts receivable.

17. Alimony, maintenance, support, and property
settlement to which the debtor is or may be
entitled. Give particulars.

18. Other liquidated debts owing debtor including
tax refunds. Give particulars.

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

20. Contingent and noncontingent interests in
estate or a decedent, death benefit plan, life
insurance policy, or trust.

21. Other contingent and unliquidated claims of
every nature, including tax refunds, counterclaims
of the debtor, and rights of setoff claims. Give
estimated value of each.

22. Patents, copyrights, and other intellectual
property. Give particulars.

23. Licenses, franchises, and other general
intangibles. Give particulars.

24. Customer lists or other compilations
containing personally identifiable information (as
defined in 11 U.S.C. §101(41A)) provided to the
debtor by individuals in connection with obtaining
a product or service from the debtor primarily for
personal, family, or household purposes.

25. Automobiles, trucks, trailers, and other
vehicles and accessories.

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DESCRIPTION AND LOCATION

OF PROPERTY

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CURRENT VALUE OF
DEBTOR’S INTEREST

IN PROPERTY,

WITHOUT

DEDUCTING ANY
SECURED CLAIM
OR EXEMPTION

Monthly child support

W

500.00

2006 Subaru Outback

J

3,983.00

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

Case 13-60797-fra7 Doc 1 Filed 03/14/13

In re

Kelii Kaimi Nuhi Aipia & Melyssa Jan Marie Aipia

Debtor

Case No.

(If known)

SCHEDULE B - PERSONAL PROPERTY

(Continuation Sheet)

TYPE OF PROPERTY

26. Boats, motors, and accessories.

27. Aircraft and accessories.

28. Office equipment, furnishings, and supplies.

29. Machinery, fixtures, equipment, and supplies
used in business.

30. Inventory.

31. Animals.

32. Crops - growing or harvested. Give
particulars.

33. Farming equipment and implements.

34. Farm supplies, chemicals, and feed.

35. Other personal property of any kind not
already listed. Itemize.

N
O
N
E

X
X
X
X

X

X

X
X

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DESCRIPTION AND LOCATION

OF PROPERTY

Residence

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CURRENT VALUE OF
DEBTOR’S INTEREST

IN PROPERTY,

WITHOUT

DEDUCTING ANY
SECURED CLAIM
OR EXEMPTION

1 dog and 2 cats
Residence

J

10.00

Wearing apparel

J

Indeterminate

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0

continuation sheets attached Total
(Include amounts from any continuation

sheets attached. Report total also on

Summary of Schedules.)

$

9,004.00

B6C (Official Form 6C) (04/10)

Case 13-60797-fra7 Doc 1 Filed 03/14/13

In re

Kelii Kaimi Nuhi Aipia & Melyssa Jan Marie Aipia

Case No.

Debtor
SCHEDULE C - PROPERTY CLAIMED AS EXEMPT

(If known)

Debtor claims the exemptions to which debtor is entitled under:
(Check one box)

11 U.S.C. § 522(b)(2)
11 U.S.C. § 522(b)(3)

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

DESCRIPTION OF PROPERTY

2006 Subaru Outback

Bank account

Furnishings

Books, pictures, dvd's

Clothing

Jewelry

Wearing apparel

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SPECIFY LAW

PROVIDING EACH

EXEMPTION

(Husb)ORS §18.345 (1)d)
(Wife)ORS §18.345 (1)d)

(Husb)ORS §18.345 (1)(o)
(Wife)ORS §18.345 (1)(o)

(Husb)ORS §18.345 (1)(f)
(Wife)ORS §18.345 (1)(f)

(Husb)ORS §18.345 (1)(a)
(Wife)ORS §18.345 (1)(a)

(Husb)ORS §18.345 (1)(b)
(Wife)ORS §18.345 (1)(b)

(Husb)ORS §18.345 (1)(b)
(Wife)ORS §18.345 (1)(b)

VALUE OF
CLAIMED

EXEMPTION

0.00
1,969.00

2.50
2.50

1,500.00
1,500.00

300.00
300.00

100.00
100.00

250.00
250.00

CURRENT

VALUE OF PROPERTY
WITHOUT DEDUCTING

EXEMPTION

3,983.00

5.00

3,000.00

600.00

200.00

500.00

(Husb)ORS §18.385
(Wife)ORS §18.385

75% of wages due
Indeterminate

Indeterminate

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Monthly child support

(Wife)ORS §18.345 (1)(i)

1 dog and 2 cats

(Husb)ORS §18.345 (1)(e)
(Wife)ORS §18.345 (1)(e)

Reliacard (child support)

(Wife)ORS §18.345 (1)(i)

500.00

5.00
5.00

206.00

500.00

10.00

206.00

*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.

Case 13-60797-fra7 Doc 1 Filed 03/14/13

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

In re _______________________________________________,

Kelii Kaimi Nuhi Aipia & Melyssa Jan Marie Aipia

Debtor

Case No. _________________________________

(If known)

SCHEDULE D - CREDITORS HOLDING SECURED CLAIMS

State the name, mailing address, including zip code and last four digits of any account number of all entities holding claims secured
by property of the debtor as of the date of filing of the petition. The complete account number of any account the debtor has with the creditor is
useful to the trustee and the creditor and may be provided if the debtor chooses to do so. List creditors holding all types of secured interests
such as judgment liens, garnishments, statutory liens, mortgages, deeds of trust, and other security interests.

List creditors in alphabetical order to the extent practicable. If a minor child is a creditor, state the child's initials and the name and
address of the child's parent or guardian, such as "A.B., a minor child, by John Doe, guardian." Do not disclose the child's name. See 11 U.S.C
§112 and Fed. R. Bankr. P. 1007(m). If all secured creditors will not fit on this page, use the continuation sheet provided.

If any entity other than a spouse in a joint case may be jointly liable on a claim, place an "X" in the column labeled "Codebtor,"
include the entity on the appropriate schedule of creditors, and complete Schedule H - Codebtors. If a joint petition is filed, state whether
husband, wife, both of them, or the marital community may be liable on each claim by placing an "H," "W," "J," or "C" in the column labeled
"Husband, Wife, Joint, or Community."

If the claim is contingent, place an "X" in the column labeled "Contingent." If the claim is unliquidated, place an "X" in the column
labeled "Unliquidated." If the claim is disputed, place an "X" in the column labeled "Disputed." (You may need to place an "X" in more than
one of these three columns.)

Total the columns labeled “Amount of Claim Without Deducting Value of Collateral” and “Unsecured Portion, if Any” in the boxes
labeled “Total(s)” on the last sheet of the completed schedule. Report the total from the column labeled “Amount of Claim Without Deducting
Value of Collateral” also on the Summary of Schedules and, if the debtor is an individual with primarily consumer debts, report the total from
the column labeled “Unsecured Portion, if Any” on the Statistical Summary of Certain Liabilities and Related Data.

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

CREDITOR’S NAME,
MAILING ADDRESS

INCLUDING ZIP CODE,
AND ACCOUNT NUMBER

(See Instructions Above.)

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DATE CLAIM WAS INCURRED,

NATURE OF LIEN, AND

DESCRIPTION AND

VALUE OF PROPERTY

SUBJECT TO LIEN

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AMOUNT

OF

CLAIM

WITHOUT
DEDUCTING
VALUE OF

COLLATERAL

UNSECURED
PORTION,

IF ANY

ACCOUNT NO.

4056

Oregon Community Credit Union
POB 77002
Springfield, OR 97475

Incurred: 2006
Security: Car

J

VALUE $

9,235.00

5,297.00

0.00

ACCOUNT NO.

ACCOUNT NO.

0

_______continuation sheets attached

VALUE $

VALUE $

Subtotal $

(Total of this page)
(Use only on last page)

Total

$

$

5,297.00
5,297.00

(Report also on
Summary of Schedules)

0.00
0.00
0.00

$
(If applicable, report
also on Statistical
Summary of Certain
Liabilities and Related
Data.)

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B6E (Official Form 6E) (04/10)

Case 13-60797-fra7 Doc 1 Filed 03/14/13

In re________________________________________________________________,

Kelii Kaimi Nuhi Aipia & Melyssa Jan Marie Aipia

Debtor

Case No.______________________________

(if known)

SCHEDULE E - CREDITORS HOLDING UNSECURED PRIORITY CLAIMS
A complete list of claims entitled to priority, listed separately by type of priority, is to be set forth on the sheets provided. Only holders of


unsecured claims entitled to priority should be listed in this schedule. In the boxes provided on the attached sheets, state the name, mailing
address, including zip code, and last four digits of the account number, if any, of all entities holding priority claims against the debtor or the
property of the debtor, as of the date of the filing of the petition. Use a separate continuation sheet for each type of priority and label each with
the type of priority.

The complete account number of any account the debtor has with the creditor is useful to the trustee and the creditor and may be provided if

the debtor chooses to do so. If a minor child is a creditor, state the child's initials and the name and address of the child's parent or guardian, such as
"A.B., a minor child, by John Doe, guardian." Do not disclose the child's name. See 11 U.S.C. § 112 and Fed.R.Bankr.P. 1007(m).

If any entity other than a spouse in a joint case may be jointly liable on a claim, place an "X" in the column labeled "Codebtor," include the


entity on the appropriate schedule of creditors, and complete Schedule H-Codebtors. If a joint petition is filed, state whether husband, wife,
both of them or the marital community may be liable on each claim by placing an "H,""W,""J," or "C" in the column labeled "Husband, Wife,
Joint, or Community." If the claim is contingent, place an "X" in the column labeled "Contingent." If the claim is unliquidated, place an "X"
in the column labeled "Unliquidated." If the claim is disputed, place an "X" in the column labeled "Disputed." (You may need to place an "X" in
more than one of these three columns.)

Report the total of claims listed on each sheet in the box labeled "Subtotals" on each sheet. Report the total of all claims listed on this


Schedule E in the box labeled "Total" on the last sheet of the completed schedule. Report this total also on the Summary of Schedules.

Report the total of amounts entitled to priority listed on each sheet in the box labeled "Subtotals" on each sheet. Report the total of all


amounts entitled to priority listed on this Schedule E in the box labeled "Totals" on the last sheet of the completed schedule. Individual debtors with
primarily consumer debts report this total also on the Statistical Summary of Certain Liabilities and Related Data.

Report the total of amounts not entitled to priority listed on each sheet in the box labeled “Subtotals” on each sheet. Report the total of all

amounts not entitled to priority listed on this Schedule E in the box labeled “Totals” on the last sheet of the completed schedule. Individual debtors
with primarily consumer debts report this total also on the Statistical Summary of Certain Liabilities and Related
Data.

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)

Domestic Support Obligations


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 in
11 U.S.C. § 507(a)(1).

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 the


appointment 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 the
cessation of business, whichever occurred first, to the extent provided in 11 U.S.C. § 507(a)(4).

Contributions to employee benefit plans

Money owed to employee benefit plans for services rendered within 180 days immediately preceding the filing of the original petition, or the


cessation of business, whichever occurred first, to the extent provided in 11 U.S.C. § 507(a)(5).

*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.

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B6E (Official Form 6E) (04/10) - Cont.

Case 13-60797-fra7 Doc 1 Filed 03/14/13

In re________________________________________________________________,

Kelii Kaimi Nuhi Aipia & Melyssa Jan Marie Aipia

Debtor

Case No.______________________________

(if known)

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).

Deposits by individuals

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).

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).

Commitments to Maintain the Capital of an Insured Depository Institution

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).

Claims for Death or Personal Injury While Debtor Was Intoxicated

Claims for death or personal injury resulting from the operation of a motor vehicle or vessel while the debtor was intoxicated from using


alcohol, a drug, or another substance. 11 U.S.C. § 507(a)(10).
alcohol, a drug, or another substance. 11 U.S.C. § 507(a)(10).

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

0

____ continuation sheets attached

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

Case 13-60797-fra7 Doc 1 Filed 03/14/13

Debtor

(If known)

In re __________________________________________,

Kelii Kaimi Nuhi Aipia & Melyssa Jan Marie Aipia








Case No. _________________________________

SCHEDULE F- CREDITORS HOLDING UNSECURED NONPRIORITY CLAIMS
State the name, mailing address, including zip code, and last four digits of any account number, of all entities holding unsecured claims without priority

against the debtor or the property of the debtor, as of the date of filing of the petition. The complete account number of any account the debtor has with the creditor is
useful to the trustee and the creditor and may be provided if the debtor chooses to do so. If a minor child is a creditor, state the child's initials and the name and address
of the child's parent or guardian, such as "A.B., a minor child, by John Doe, guardian." Do not disclose the child's name. See 11 U.S.C. § 112 and Fed. R. Bankr. P.
1007(m). Do not include claims listed in Schedules D and E. If all creditors will not fit on this page, use the continuation sheet provided.

If any entity other than a spouse in a joint case may be jointly liable on a claim, place an "X" in the column labeled "Codebtor," include the entity on the

appropriate schedule of creditors, and complete Schedule H - Codebtors. If a joint petition is filed, state whether husband, wife, both of them, or the marital
community may be liable on each claim by placing an "H," "W," "J," or "C" in the column labeled "Husband, Wife, Joint, or Community."

If the claim is contingent, place an "X" in the column labeled "Contingent." If the claim is unliquidated, place an "X" in the column labeled

"Unliquidated." If the claim is disputed, place an "X" in the column labeled "Disputed." (You may need to place an "X" in more than one of these three columns.)

Report the total of all claims listed on this schedule in the box labeled "Total" on the last sheet of the completed schedule. Report this total also on the
Summary of Schedules and, if the debtor is an individual with primarily consumer debts, report this total also on the Statistical Summary of Certain Liabilities and
Related Data.

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

CREDITOR’S NAME,
MAILING ADDRESS

INCLUDING ZIP CODE,
AND ACCOUNT NUMBER

(See instructions above.)

R
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8890

ACCOUNT NO.
ARS National Services, Inc.
POB 469046
Escondido, CA 92029-9046

8890

ACCOUNT NO.
Citi Cards Master Card
POB 183564
Columbus, OH 43218-2564

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9233

ACCOUNT NO.
Discover
POB 3025
New Albany, OH 43054-3025



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0002
ACCOUNT NO.
Eugene Urgent Care
1292 High Str., Ste. 224
Eugene, OR 97401

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DATE CLAIM WAS INCURRED AND

CONSIDERATION FOR CLAIM.

IF CLAIM IS SUBJECT TO SETOFF,

SO STATE.

T
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AMOUNT

OF

CLAIM

Consideration: Assigned by Citibank,
N.A./Citi Mastercard

Notice Only

Consideration: Credit card debt

Consideration: Credit card debt

Consideration: Medical Services

J

J

J

4,255.99

8,628.05

275.12

3

_______continuation sheets attached

Subtotal $

13,159.16

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.)

$

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

Case 13-60797-fra7 Doc 1 Filed 03/14/13

In re __________________________________________________,

Kelii Kaimi Nuhi Aipia & Melyssa Jan Marie Aipia







Case No. _________________________________

Debtor

(If known)

SCHEDULE F- CREDITORS HOLDING UNSECURED NONPRIORITY CLAIMS

(Continuation Sheet)

CREDITOR’S NAME,
MAILING ADDRESS

INCLUDING ZIP CODE,
AND ACCOUNT NUMBER

(See instructions above.)

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DATE CLAIM WAS INCURRED AND

CONSIDERATION FOR CLAIM.

IF CLAIM IS SUBJECT TO SETOFF,

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AMOUNT

OF

CLAIM

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ACCOUNT NO.

IRS
Insolvency Operation
POB 7346
Philadelphia, PA 19101-7346

ACCOUNT NO.

0639

Kay Jewelers
POB 740425
Cincinnati, OH 45274-0425

7066

ACCOUNT NO.
McKenzie-Willamette Medical Center
1460 G Street
Springfield, OR 97477

ACCOUNT NO.
ODR
Bankruptcy Unit Collect. Div
955 Center St. NE 353
Salem OR 97301-2553

6899

ACCOUNT NO.
Oregon Community Credit Union
POB 77002
Springfield, OR 97475

J

J

J

Consideration: Credit card debt

Consideration: Medical Services

Consideration: Credit card debt

Notice Only

1,602.85

323.06

Notice Only

446.00

1

3

Sheet no. _____ of _____continuation sheets attached
to Schedule of Creditors Holding Unsecured
Nonpriority Claims

Subtotal $

2,371.91

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.)

$

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

Case 13-60797-fra7 Doc 1 Filed 03/14/13

In re __________________________________________________,

Kelii Kaimi Nuhi Aipia & Melyssa Jan Marie Aipia







Case No. _________________________________

Debtor

(If known)

SCHEDULE F- CREDITORS HOLDING UNSECURED NONPRIORITY CLAIMS

(Continuation Sheet)

CREDITOR’S NAME,
MAILING ADDRESS

INCLUDING ZIP CODE,
AND ACCOUNT NUMBER

(See instructions above.)

R
O
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Y
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I
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O
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DATE CLAIM WAS INCURRED AND

CONSIDERATION FOR CLAIM.

IF CLAIM IS SUBJECT TO SETOFF,

T
N
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G
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I
T
N
O
C

D
E
T
A
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U
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I
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AMOUNT

OF

CLAIM

E
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ACCOUNT NO.

Various

Peace Health Laboratories
POB 77003
Springfield, OR 94777

ACCOUNT NO.

5374

Peace Health Medical Group
POB 24410
Eugene, OR 97402

6939

ACCOUNT NO.
Prevention Plus Clinic
1800 Centennial Blvd., Ste 6
Springfield, OR 97477

ACCOUNT NO.
Professional Credit Services
POB 7548
Eugene, OR 97401

9931

ACCOUNT NO.
Radiology Associates, PC
POB 53
Eugene, OR 97440

Consideration: Medical Services

Consideration: Medical Services

Incurred: 1/2012
Consideration: Medical Services

Consideration: Assigned debt

Consideration: Medical Services

J

W

J

125.16

10.00

228.00

Notice Only

1,819.69

2

3

Sheet no. _____ of _____continuation sheets attached
to Schedule of Creditors Holding Unsecured
Nonpriority Claims

Subtotal $

2,182.85

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.)

$

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

Case 13-60797-fra7 Doc 1 Filed 03/14/13

In re __________________________________________________,

Kelii Kaimi Nuhi Aipia & Melyssa Jan Marie Aipia







Case No. _________________________________

Debtor

(If known)

SCHEDULE F- CREDITORS HOLDING UNSECURED NONPRIORITY CLAIMS

(Continuation Sheet)

CREDITOR’S NAME,
MAILING ADDRESS

INCLUDING ZIP CODE,
AND ACCOUNT NUMBER

(See instructions above.)

R
O
T
B
E
D
O
C

T
N
I

O
J

,

E
F
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W


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D
N
A
B
S
U
H

Y
T
I
N
U
M
M
O
C
R
O

DATE CLAIM WAS INCURRED AND

CONSIDERATION FOR CLAIM.

IF CLAIM IS SUBJECT TO SETOFF,

T
N
E
G
N
I
T
N
O
C

D
E
T
A
D
I
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I
L
N
U

D
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S
I
D

AMOUNT

OF

CLAIM

ACCOUNT NO.

6674

Sacred Heart Medical Center
c/o Peace Health
POB 569
Eugene, OR 97440-0569

ACCOUNT NO.

Trans Union Corporation
POB 1000
Chester, PA 19022

8581

ACCOUNT NO.
U.S. Department of Ed.
POB 7860
Madison, WI 53707-7860

ACCOUNT NO.

Incurred: 6/21/2011
Consideration: Medical Services

Consideration: credit reporting agency

Consideration: Student loan

J

W

565.89

Notice Only

15,047.11

E
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ACCOUNT NO.

3

3

Sheet no. _____ of _____continuation sheets attached
to Schedule of Creditors Holding Unsecured
Nonpriority Claims

Subtotal $

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.)

$

15,613.00
33,326.92

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

Case 13-60797-fra7 Doc 1 Filed 03/14/13

In re

Kelii Kaimi Nuhi Aipia & Melyssa Jan Marie Aipia

Debtor

Case No.

(if known)

SCHEDULE G - EXECUTORY CONTRACTS AND UNEXPIRED LEASES

Describe all executory contracts of any nature and all unexpired leases of real or personal property. Include any timeshare interests.
State nature of debtor’s interest in contract, i.e., “Purchaser,” “Agent,” etc. State whether debtor is the lessor or lessee of a lease. Provide the
names and complete mailing addresses of all other parties to each lease or contract described. If a minor child is a party to one of the leases or
contracts, state the child's initials and the name and address of the child's parent or guardian, such as "A.B., a minor child, by John Doe,
guardian." Do not disclose the child’s name. See 11 U.S.C. § 112 and Fed. R. Bankr. P. 1007(m).

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

DESCRIPTION OF CONTRACT OR LEASE AND NATURE OF

DEBTOR’S INTEREST. STATE WHETHER LEASE IS FOR
NONRESIDENTIAL REAL PROPERTY. STATE CONTRACT

NUMBER OF ANY GOVERNMENT CONTRACT.

NAME AND MAILING ADDRESS, INCLUDING ZIP CODE,

OF OTHER PARTIES TO LEASE OR CONTRACT.

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

Case 13-60797-fra7 Doc 1 Filed 03/14/13

In re

Kelii Kaimi Nuhi Aipia & Melyssa Jan Marie Aipia

Case No.

Debtor

(if known)

SCHEDULE H - CODEBTORS

Provide the information requested concerning any person or entity, other than a spouse in a joint case, that is also liable on any

debts listed by debtor in the schedules of creditors. Include all guarantors and co-signers. If 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 the eight year period immediately preceding the commencement of the case, identify the
name of the debtor’s spouse and of any former spouse who resides or resided with the debtor in the community property state,
commonwealth, or territory. Include all names used by the nondebtor spouse during the eight years immediately preceding the
commencement of this case. If a minor child is a codebtor or a creditor, state the child's initials and the name and address of the child's
parent or guardian, such as "A.B., a minor child, by John Doe, guardian." Do not disclose the child's name. See 11 U.S.C. § 112 and
Fed. Bankr. P. 1007(m).

Check this box if debtor has no codebtors.

NAME AND ADDRESS OF CODEBTOR

NAME AND ADDRESS OF CREDITOR

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

Case 13-60797-fra7 Doc 1 Filed 03/14/13

Kelii Kaimi Nuhi Aipia & Melyssa Jan Marie Aipia

In re

Case





Debtor
SCHEDULE I - CURRENT INCOME OF INDIVIDUAL DEBTOR(S)

(if known)

















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 is
filed, unless the spouses are separated and a joint petition is not filed. Do not state the name of any minor child. The average monthly income
calculated on this form may differ from the current monthly income calculated on Form 22A, 22B, or 22C.

Debtor’s Marital
Status:

Separated

RELATIONSHIP(S):

son, son

AGE(S):

12, 16

DEPENDENTS OF DEBTOR AND SPOUSE

Employment: DEBTOR
Occupation
Name of Employer
How long employed
Address of Employer

Fire Sprinkler Installer
BDH Fire Protections
6 yrs
1535 Charneton Str. Ste. 11
Eugene, OR 97401

SPOUSE

Medical Assistant
Oregon Medical Group
4 Mos.
POB 1648
Eugene, OR 97440

INCOME: (Estimate of average or projected monthly income at time case filed)
1. Monthly gross wages, salary, and commissions

(Prorate if not paid monthly.)

2. Estimated monthly overtime
3. SUBTOTAL
4. LESS PAYROLL DEDUCTIONS

a. Payroll taxes and social security
b. Insurance
c. Union Dues
d. Other (Specify:___________________________________________________________)

(D)Misc.

5. SUBTOTAL OF PAYROLL DEDUCTIONS
6.. TOTAL NET MONTHLY TAKE HOME PAY

7. Regular income from operation of business or profession or farm
(Attach detailed statement)
8. Income from real property
9. Interest and dividends
10. Alimony, maintenance or support payments payable to the debtor for the
debtor’s use or that of dependents listed above.
11. Social security or other government assistance
( Specify)
12. Pension or retirement income
13. Other monthly income
(Specify)
14. SUBTOTAL OF LINES 7 THROUGH 13

15. AVERAGE MONTHLY INCOME (Add amounts shown on Lines 6 and 14)

16. COMBINED AVERAGE MONTHLY INCOME (Combine column totals
from line 15)

DEBTOR SPOUSE

$ _____________ $ _____________

$ _____________ $ _____________

$ _____________ $ _____________

2,099.00
0.00
2,099.00

1,109.00
0.00
1,109.00

$ _____________ $ _____________
$ _____________ $ _____________
$ _____________ $ _____________
$ _____________ $ _____________

361.00
0.00
0.00
246.00

340.12
0.00
0.00
0.00

$ _____________ $ _____________

$ _____________ $ _____________

607.00
1,492.00

340.12
768.88

$ _____________ $ _____________

0.00

0.00

$ _____________ $ _____________
$ _____________ $ _____________

0.00
0.00

0.00
0.00

$ _____________ $ _____________

594.23

0.00

$ _____________ $ _____________

0.00

0.00

$ _____________ $ _____________
$ _____________ $ _____________
$ _____________ $ _____________
$ _____________ $ _____________

0.00
0.00
0.00
594.23
1,363.11

0.00
0.00
0.00
0.00
1,492.00

$ _____________ $ _____________

2,855.11
$ _____________

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

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

None

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

Case 13-60797-fra7 Doc 1 Filed 03/14/13

In re

Kelii Kaimi Nuhi Aipia & Melyssa Jan Marie Aipia

Debtor

Case No.

(if known)

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 on this form may differ from the deductions from income allowed on Form 22A 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.”

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

a. Are real estate taxes included?
b. Is property insurance included?

2. Utilities: a. Electricity and heating fuel

b. Water and sewer

Yes ________ No ________
Yes ________ No ________

c. Telephone
d. Other ___________________________________________________________________

Garbage

3. Home maintenance (repairs and upkeep)
4. Food
5. Clothing
6. Laundry and dry cleaning
7. Medical and dental expenses
8. Transportation (not including car payments)
9. Recreation, clubs and entertainment, newspapers, magazines, etc.
10.Charitable contributions
11.Insurance (not deducted from wages or included in home mortgage payments)

a. Homeowner’s or renter’s
b. Life
c. Health
d.Auto
e. Other

12.Taxes (not deducted from wages or included in home mortgage payments)
(Specify)
13. Installment payments: (In chapter 11, 12, and 13 cases, do not list payments to be included in the plan)

a. Auto
b. Other
c. Other

E
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$ _____________
600.00

$ ______________
82.21
$ ______________
75.00
$ ______________
85.00
$ ______________
47.00
$ ______________
400.00
$ ______________
250.00
$ ______________
100.00
$ ______________
125.00
$ ______________
0.00
$ ______________
0.00
$ ______________
85.00
$ ______________
100.00

$ ______________
0.00
$ ______________
0.00
$ ______________
171.00
$ ______________
52.51
$ ______________
0.00

$ ______________
0.00

$______________
0.00
$ ______________
0.00
$ ______________
0.00
$ ______________
500.00
$ ______________
0.00
$ ______________
0.00
$______________
100.00
$______________
2,772.72

14. Alimony, maintenance, and support paid to others
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)
17. Other
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:

pet exp., pers. hygiene, children's acitivities

None

20. STATEMENT OF MONTHLY NET INCOME

a. Average monthly income from Line 15 of Schedule I
b. Average monthly expenses from Line 18 above
c. Monthly net income (a. minus b.)

(Includes spouse income of $1,363.11. See Schedule I)
(Includes spouse's separate expenditures of $1,900.00. See pg 2)
(Net includes Debtor/Spouse combined Amounts)

2,855.11
$ ______________
$ ______________
4,672.72
-1,817.61
$ ______________

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

Case 13-60797-fra7 Doc 1 Filed 03/14/13

In re

Kelii Kaimi Nuhi Aipia & Melyssa Jan Marie Aipia

Debtor

Case No.

(if known)

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 on this form may differ from the deductions from income allowed on Form 22A or 22C.

SPOUSE

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.”

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

a. Are real estate taxes included?
b. Is property insurance included?

2. Utilities: a. Electricity and heating fuel

b. Water and sewer

Yes ________ No ________
Yes ________ No ________

c. Telephone
d. Other ___________________________________________________________________

Internet

3. Home maintenance (repairs and upkeep)
4. Food
5. Clothing
6. Laundry and dry cleaning
7. Medical and dental expenses
8. Transportation (not including car payments)
9. Recreation, clubs and entertainment, newspapers, magazines, etc.
10.Charitable contributions
11.Insurance (not deducted from wages or included in home mortgage payments)

a. Homeowner’s or renter’s
b. Life
c. Health
d.Auto
e. Other

12.Taxes (not deducted from wages or included in home mortgage payments)
(Specify)
13. Installment payments: (In chapter 11, 12, and 13 cases, do not list payments to be included in the plan)

a. Auto
b. Other
c. Other

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$ _____________
345.00

$ ______________
70.00
$ ______________
35.00
$ ______________
85.00
$ ______________
50.00
$ ______________
0.00
$ ______________
250.00
$ ______________
125.00
$ ______________
50.00
$ ______________
0.00
$ ______________
250.00
$ ______________
200.00
$ ______________
0.00

$ ______________
0.00
$ ______________
0.00
$ ______________
0.00
$ ______________
65.00
$ ______________
0.00

$ ______________
0.00

$______________
275.00
$ ______________
0.00
$ ______________
0.00
$ ______________
0.00
$ ______________
0.00
$ ______________
0.00
$______________
100.00
$______________
1,900.00

14. Alimony, maintenance, and support paid to others
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)
17. Other
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:

pers. hyg., gifts, child activities

None

20. STATEMENT OF MONTHLY NET INCOME

a. Average monthly income from Line 15 of Schedule I
b. Average monthly expenses from Line 18 above
c. Monthly net income (a. minus b.)

(For totals, see Debtor's Schedule J)
(For totals, see Debtor's Schedule J)
(For totals, see Debtor's Schedule J)

$ ______________
see pg. 1
$ ______________
see pg. 1
$ ______________
see pg. 1

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

Case 13-60797-fra7 Doc 1 Filed 03/14/13

Kelii Kaimi Nuhi Aipia & Melyssa Jan Marie Aipia

In re

Debtor

Case No.

(If known)

DECLARATION CONCERNING DEBTOR'S SCHEDULES

DECLARATION UNDER PENALTY OF PERJURY BY INDIVIDUAL DEBTOR


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 _______ sheets, and that they

19

Date

2-6-13

2-6-13

Date

Signature:

/s/ Kelii Kaimi Nuhi Aipia

Debtor

Signature:

/s/ Melyssa Jan Marie Aipia

(Joint Debtor, if any)

[If joint case, both spouses must sign.]

-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

DECLARATION AND SIGNATURE OF NON-ATTORNEY BANKRUPTCY PETITION PREPARER (See 11 U.S.C. § 110)

I declare under penalty of perjury that: (1) I am a bankruptcy petition preparer as defined in 11 U.S.C. § 110; (2) I prepared this document for
compensation and have provided the debtor with a copy of this document and the notices and information required under 11 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 setting a maximum fee for services chargeable
by bankruptcy petition preparers, I have given the debtor notice of the maximum amount before preparing any document for filing for a debtor or
accepting any fee from the debtor, as required by that section.

Printed or Typed Name and Title, if any,
of Bankruptcy Petition Preparer
If the bankruptcy petition preparer is not an individual, state the name, title (if any), address, and social security number of the officer, principal, responsible person, or partner
who signs this document.

(Required by 11 U.S.C. § 110.)

Social Security No.

Address

X

Signature of Bankruptcy Petition Preparer

Date

Names and Social Security numbers of all other individuals who prepared or assisted in preparing this document, unless the bankruptcy petition preparer is not an individual:

If more than one person prepared this document, attach additional signed sheets conforming to the appropriate Official Form for each person.

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.
-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

DECLARATION UNDER PENALTY OF PERJURY ON BEHALF OF A CORPORATION OR PARTNERSHIP

I, the __________________________________ [the president or other officer or an authorized agent of the corporation or a member
or an authorized agent of the partnership ] of the ___________________________________ [corporation or partnership] named as debtor
in this case, declare under penalty of perjury that I have read the foregoing summary and schedules, consisting of _______sheets (total
shown on summary page plus 1),and that they are true and correct to the best of my knowledge, information, and belief.

Date

Signature:

-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

[An individual signing on behalf of a partnership or corporation must indicate position or relationship to debtor.]

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 and 3571.

[Print or type name of individual signing on behalf of debtor.]

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B7 (Official Form 7) (12/12)

Case 13-60797-fra7 Doc 1 Filed 03/14/13
UNITED STATES BANKRUPTCY COURT

District of Oregon

In Re

Kelii Kaimi Nuhi Aipia & Melyssa Jan Marie Aipia

Case No.

(if known)

STATEMENT OF FINANCIAL AFFAIRS


This statement is to be completed by every debtor. Spouses filing a joint petition may file a single statement on which
the information for both spouses is combined. If the case is filed under chapter 12 or chapter 13, a married debtor must furnish
information for both spouses whether or not a joint petition is filed, unless the spouses are separated and a joint petition is not
filed. An individual debtor engaged in business as a sole proprietor, partner, family farmer, or self-employed professional, should
provide the information requested on this statement concerning all such activities as well as the individual's personal affairs. To
indicate payments, transfers and the like to minor children, state the child's initials and the name and address of the child's parent
or guardian, such as "A.B., a minor child, by John Doe, guardian." Do not disclose the child's name. See 11 U.S.C. § 112 and Fed.
R. Bankr. P. 1007(m).

Questions 1 - 18 are to be completed by all debtors. Debtors that are or have been in business, as defined below, also


must complete Questions 19 - 25. If the answer to an applicable question is "None," mark the box labeled "None." If
additional space is needed for the answer to any question, use and attach a separate sheet properly identified with the case name,
case number (if known), and the number of the question.

DEFINITIONS

"In business." A debtor is "in business" for the purpose of this form if the debtor is a corporation or partnership. An

individual debtor is "in business" for the purpose of this form if the debtor is or has been, within six years immediately preceding
the filing of this bankruptcy case, any of the following: an officer, director, managing executive, or owner of 5 percent or more of
the voting or equity securities of a corporation; a partner, other than a limited partner, of a partnership; a sole proprietor or self-
employed full-time or part-time. An individual debtor also may be “in business” for the purpose of this form if the debtor engages
in a trade, business, or other activity, other than as an employee, to supplement income from the debtor’s primary employment.

"Insider." The term "insider" includes but is not limited to: relatives of the debtor; general partners of the debtor and

their relatives; corporations of which the debtor is an officer, director, or person in control; officers, directors, and any persons in
control of a corporate debtor and their relatives; affiliates of the debtor and insiders of such affiliates; any managing agent of the
debtor. 11 U.S.C. § 101(2), (31).



1. Income from employment or operation of business

None

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

SOURCE

2013(db)

AMOUNT
5.231.58

2012(db)

44,270.00

2011(db)

51,067.00

joint

joint

2013(jdb)

2,067.70

2012(jdb)

see above

2011(jdb)

see above

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Case 13-60797-fra7 Doc 1 Filed 03/14/13

B7 (12/12)

2

2. Income other than from employment or operation of business

None

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

AMOUNT

SOURCE

2012 (db)

2011(db)

2012(jdb)

(jdb)

2,535.00

1,014.00

1,901.52

unemployment compensation

unemployment compensation

Child support

None

3. Payments to creditors

Complete a. or b., as appropriate, and c.
a. Individual or joint debtor(s) with primarily consumer debts: List all payments on loans, installment purchases of
goods or services, and other debts to any creditor made within 90 days immediately preceding the commencement of
this case unless the 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 alternative repayment schedule under a plan by an approved nonprofit budgeting and creditor
counseling agency. (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 is not filed.)

NAME AND ADDRESS OF CREDITOR

DATES OF
PAYMENTS

AMOUNT

PAID

AMOUNT STILL

OWING

Oregon Community Credit Union
POB 77002
Springfield, OR 97475

Monthly - Car payments

275/mo

5,297.00

None

b. Debtor whose debts are not primarily consumer debts: List each payment or other transfer to any creditor made
within 90 days immediately preceding the commencement of the case unless the aggregate value of all property that
constitutes or is affected by such transfer is less than $5,850*. If the debtor is an individual, indicate with an asterisk
(*) any payments that were made to a creditor on account of a domestic support obligation or as part of an
alternative repayment schedule under a plan by an approved nonprofit budgeting and credit counseling agency.
(Married debtors filing under chapter 12 or chapter 13 must include payments and other transfers by either or both
spouses whether or not a joint petition is filed, unless the spouses are separated and a joint petition is not filed.)

*Amount subject to adjustment on 4/01/13, and every three years thereafter with respect to cases commenced on or after date of adjustment.
NAME AND ADDRESS OF CREDITOR

AMOUNT

AMOUNT STILL

DATES OF
PAYMENTS

AND RELATIONSHIP TO DEBTOR

PAID

OWING

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Case 13-60797-fra7 Doc 1 Filed 03/14/13

3

B7 (12/12)

None

c. All debtors: List all payments made within one year immediately preceding the commencement of this case to or
for the benefit 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 is not filed.)

NAME AND ADDRESS OF CREDITOR

AND RELATIONSHIP TO DEBTOR

DATES OF
PAYMENTS

AMOUNT PAID

AMOUNT STILL

OWING

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 the filing of this bankruptcy case. (Married debtors filing under chapter 12 or chapter 13 must include
information concerning either 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 PROCEEDING

COURT OR

AGENCY AND LOCATION

STATUS OR
DISPOSITION

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 include information 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 OF

PERSON FOR WHOSE BENEFIT

PROPERTY WAS SEIZED

DATE OF
SEIZURE

DESCRIPTION AND

VALUE OF PROPERTY

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 of foreclosure or returned to the seller, within one year immediately preceding the commencement of this case.
(Married debtors filing under chapter 12 or chapter 13 must include information 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 OF

CREDITOR OR SELLER

DATE OF REPOSESSION,
FORECLOSURE SALE,
TRANSFER OR RETURN

DESCRIPTION AND

VALUE OF PROPERTY

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Case 13-60797-fra7 Doc 1 Filed 03/14/13

B7 (12/12)

4

6. Assignments and Receiverships

None

a. Describe any assignment of property for the benefit of creditors made within 120 days immediately preceding
the commencement of this case. (Married debtors filing under chapter 12 or chapter 13 must include any
assignment by 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 OF
ASSIGNEE

DATE OF ASSIGNMENT

TERMS OF

ASSIGNMENT

OR SETTLEMENT

None

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
must include information 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 LOCATION
OF COURT CASE TITLE

& NUMBER

DATE OF
ORDER

DESCRIPTION AND

VALUE OF PROPERTY

NAME AND
ADDRESS OF
CUSTODIAN

7. Gifts

None

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 charitable contributions aggregating less than $100 per recipient. (Married debtors filing under chapter
12 or chapter 13 must include gifts or contributions by 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 OF

PERSON OR ORGANIZATION

8. Losses

RELATIONSHIP

TO DEBTOR, IF ANY

DATE OF

GIFT

DESCRIPTION AND

VALUE OF GIFT

None

List all losses from fire, theft, other casualty or gambling within one year immediately preceding the
commencement of 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 a joint petition is not filed.)

DESCRIPTION
AND VALUE
OF PROPERTY

DESCRIPTION OF CIRCUMSTANCES, AND, IF LOSS

WAS COVERED IN WHOLE OR IN PART BY

INSURANCE, GIVE PARTICULARS

DATE OF

LOSS

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Case 13-60797-fra7 Doc 1 Filed 03/14/13

B7 (12/12)

5

9. Payments related to debt counseling or bankruptcy

None

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

NAME AND ADDRESS

OF PAYEE

DATE OF PAYMENT,
NAME OF PAYOR IF

OTHER THAN DEBTOR

AMOUNT OF MONEY OR

DESCRIPTION AND

VALUE OF PROPERTY

Harder, Wells, Baron & Manning
474 Willamette Str.,
Eugene, OR 97401

9/2012

$1500.00 Fees & costs.

Cricket Debt Counseling

1/3/2013

Credit Counseling Class $36.00

10. Other transfers

None

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

NAME AND ADDRESS OF TRANSFEREE,

RELATIONSHIP TO DEBTOR

DATE

DESCRIBE PROPERTY
TRANSFERRED AND
VALUE RECEIVED

Springcress Properties, LLC
Relationship: None

January 10, 2013

residence; $104,500; negative equity

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

None

NAME OF TRUST OR OTHER DEVICE

DATE(S) OF
TRANSFER(S)

AMOUNT OF MONEY OR

DESCRIPTION AND

VALUE OF PROPERTY OR

DEBTOR'S INTEREST IN PROPERTY

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B7 (12/12)

None

Case 13-60797-fra7 Doc 1 Filed 03/14/13

6

11. Closed financial accounts

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 debtors filing under chapter 12 or chapter 13 must include information concerning accounts or
instruments held by 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 OF
INSTITUTION

TYPE OF ACCOUNT, LAST FOUR
DIGITS OF ACCOUNT NUMBER,

AND AMOUNT OF FINAL BALANCE

AMOUNT AND
DATE OF SALE
OR CLOSING

12. Safe deposit boxes

None

List each safe deposit or other box or depository in which the debtor has or had securities, cash, or other
valuables within one year immediately preceding the commencement of this case. (Married debtors filing under
chapter 12 or chapter 13 must include boxes or depositories 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 OF BANK

OR OTHER DEPOSITORY

NAMES AND ADDRESSES OF
THOSE WITH ACCESS TO BOX

OR DEPOSITORY

DESCRIPTION OF

CONTENTS

DATE OF

TRANSFER OR

SURRENDER, IF ANY

13. Setoffs

None

List all setoffs made by any creditor, including a bank, against a debt or deposit of the debtor within 90 days
preceding the commencement of this case. (Married debtors filing under chapter 12 or chapter 13 must include
information concerning 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 OF CREDITOR

DATE
OF

SETOFF

14. Property held for another person

None

List all property owned by another person that the debtor holds or controls.

AMOUNT

OF

SETOFF

NAME AND

ADDRESS OF OWNER

DESCRIPTION AND

VALUE OF PROPERTY

LOCATION OF PROPERTY

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B7 (12/12)

None

Case 13-60797-fra7 Doc 1 Filed 03/14/13

7

15. Prior address of debtor

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

ADDRESS

NAME USED

DATES OF OCCUPANCY

5330 "B" Street
Springfield, OR 97478

Same

April 2004 to January, 2013

None

16. Spouses and Former Spouses

If 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 spouse who resides or resided with the debtor in the community property state.

NAME

17. Environmental Sites

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 of hazardous 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 or formerly 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

None

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

SITE NAME

AND ADDRESS

NAME AND ADDRESS

OF GOVERNMENTAL UNIT

DATE OF
NOTICE

ENVIRONMENTAL

LAW

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Case 13-60797-fra7 Doc 1 Filed 03/14/13

8

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

B7 (12/12)

None

SITE NAME

AND ADDRESS

NAME AND ADDRESS

OF GOVERNMENTAL UNIT

DATE OF
NOTICE

ENVIRONMENTAL

LAW

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

None

NAME AND ADDRESS

OF GOVERNMENTAL UNIT

18. Nature, location and name of business

DOCKET NUMBER

STATUS OR DISPOSITION

None

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
managing executive of a corporation, partnership, sole proprietorship, or was self-employed in a trade, profession, or
other activity either full- or part-time within 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 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.

If the debtor is a corporation, 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.

NAME

LAST FOUR DIGITS OF
SOCIAL-SECURITY OR
OTHER INDIVIDUAL
TAXPAYER-I.D. NO.
(ITIN)/ COMPLETE EIN

ADDRESS

NATURE OF BUSINESS BEGINNING AND
ENDING DATES

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

None

NAME

ADDRESS

[Questions 19 - 25 are not applicable to this case]

* * * * * *

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Case 13-60797-fra7 Doc 1 Filed 03/14/13

B7 (12/12)

9

[If completed by an individual or individual and spouse]

I declare under penalty of perjury that I have read the answers contained in the foregoing statement of financial affairs and any attachments
thereto and that they are true and correct.
2-6-13

Signature
of Debtor

/s/ Kelii Kaimi Nuhi Aipia
KELII KAIMI NUHI AIPIA

Date

Date

2-6-13

Signature
of Joint Debtor

/s/ Melyssa Jan Marie Aipia
MELYSSA JAN MARIE AIPIA

0

_____ continuation sheets attached

Penalty for making a false statement: Fine of up to $500,000 or imprisonment for up to 5 years, or both. 18 U.S.C. §152 and 3571

DECLARATION AND SIGNATURE OF NON-ATTORNEY BANKRUPTCY PETITION PREPARER (See 11 U.S.C. § 110)
I declare under penalty of perjury that: (1) I am a bankruptcy petition preparer as defined in 11 U.S.C. § 110; (2) I prepared this document for
compensation and have provided the debtor with a copy of this document and the notices and required under 11U.S.C. §§ 110(b), 110(h), and 342(b); (3) if
rules or guidelines have been promulgated pursuant to 11 U.S.C. § 110 setting a maximum fee for services chargeable by bankruptcy petition preparers, I
have given the debtor notice of the maximum amount before preparing any document for filing for a debtor or accepting any fee from the debtor, as required
in that section.

Printed or Typed Name and Title, if any, of Bankruptcy Petition Preparer
Social Security No. (Required by 11 U.S.C. § 110(c).)
If the bankruptcy petition preparer is not an individual, state the name, title (if any), address, and social security number of the officer, principal, responsible person, or
partner who signs this document.

Address

X
Signature of Bankruptcy Petition Preparer

Date

Names and Social Security numbers of all other individuals who prepared or assisted in preparing this document unless the bankruptcy petition preparer is
not an individual:

If more than one person prepared this document, attach additional signed sheets conforming to the appropriate Official Form for each person.

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. 18 U.S.C. §156.

E
D
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