Case 13-13096-MAM Doc 6 Filed 02/12/13 Page 1 of 4 Bl (Of?cial Form 1) (12/11) UNITED Stan?s BANKRUPTCY COURT Southern District of Florida Name of Debtor (il'individual, enter Last, First, Middle): Siskind, Jeffrey Marc t, die): Name ot?.loint Debtor (Spouse) (Last, Firs All Other Names used by the Joint Debtor in the last 8 years (include married, maiden, and trade names): All Other Names used by the Debtor in the last 8 years (include married, maiden, and trade names): See Exhibit A attached hereto Last four digits ofSoc. Sec. or Individual-Taxpayer l.D. (HIM/Complete (if more than one, state all): 3282 Street Address of Debtor (No. and Street, City, and State): 3465 Santa Barbara Drive Wellington, FL 33414 Lost four digits of Soc. See. or lndividual-laxpayer 1.D. (l'l'lNyComplete (if more than one, state all): Street Address ot?Joint Debtor (No. and Street, City. and State): EIP CODE 33414 I EIP CODE I County or oFthe Princrpal Place of Business C0unty ofResidence or ot~ the Principal Place ot?liusmess Palm Beach Mailing Address 01? Debtor (it?dit?t?crent from street address) Mailing Address ol?Joint Debtor (il'dtt?t?erent From street address) Ell" CODE I Iiin?ODIi I IZIP CODE I Location of Principal Assets ot?Business Debtor (it?dii'l'crent from street address above): Type of Debtor Nature of Business Chapter of Bankruptcy Code Under Which [Form of Organization) (Check one box.) the Petition is Filed (Check one box.) (Check one box.) El Health Care Business El Chapter 7 Chapter 15 Petition for individual (includes Joint Debtors) E1 Single Asset Real Estate as de?ned in Chapter 9 Recognition ofa lioreign See Exhibit!) on page 2 ofthr'sform. ll U.S.C. 101(5113) Chapter 11 Main Proceeding Corporation (includes LLC and UP) Railroad CI Chapter 12 Chapter 15 Petition for El Partnership Stockbroker Chapter 13 Recognition ot'a Foreign Other debtor is not one 0101:: above entities, check Commodity Broker Nonmain Proceeding this box and state type ot?entity below.) Clearing Bank Other Chapter 15 Debtors Tax-Exempt Entity Nature of Debts Country ot?dehtor?s center of main interests: (Cheek box, '1 applicable.) (Check Debts are primarily consumer Debts are Debtor is a tax?exempt organization debts, defined in 1 U.S.C primarily Each country in which a foreign proceeding by, regarding, or under title 26 ot?thc United States 101(8) as ?incurred by an business debts. against debtor is pending: Code (the internal Revenue Code). individual primarily For a personal, family, or household purpose.? Filing Fee (Check one box.) Chapter 11 Debtors Check one box: Full Filing Fee attached. Debtor is a small business debtor as de?ned in 11 U.S.C. 101(5 1 D). Debtor is not a small business debtor as defined in 11 USC. 101(Sll)). El 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 Of?cial Form 3A. Check if: Debtor's aggregate noncontingent liquidated debts (excluding debts owed to insiders or af?liates) are less than $2,343,300 (amount subject to adjustment Filing Fee waiver requested (applicable to chapter 7 individuals only). Must on 4/01/13 and every three years thereafter). attach signed application for the court?s consideration. See Of?cial Form BB. Check all applicable boxes: A plan is being ?led with this petition. Acceptances ofthe plan were solicited from one or more classes in accordance with 11 USC. 1126(1)). Statistical/Administrative Information SPACE IS FOR COURT USE ONLY [3 Debtor estimates that funds 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 ot?Crcditors 1:1 1:1 1:1 1:1 1-49 50-99 100-199 200-999 1000- 5,001- 10,001- 25.001- 50,001- Over 5,000 10,000 25,000 50,000 100,000 100,000 Estimated Assets El 1:1 $0 to $50.00] to $100,001 to $500,001 $1,000,001 $10,000,001 $50,000,001 $100,000,001 $500,000,001 More than $50,000 $100,000 $500,000 $100 to $500 to $1 billion $1 billion million million million million million Estimated Liabilities El E1 Cl $0 to $50.00] to $100,001 to $500,001 $1,000,001 $10,000,001 $50,000,001 $100,000,001 $500,000,001 More than $50,000 $100,000 $500,000 $100 to $500 to $1 billion $1 billion million million million million million Bl (Of?cial Form I) I) Case 13-13096-MAM Doc 6 Filed 02/12/13 Page 2 of 4 Page 2 Voluntary Petition (This page mus! be completed and ?led in everv case.) l'D gig?in .tgl'liey M. All Prior Bankruptcy Cases Filed Within Last 8 Years (If more than two, attach additional sheet.) Location Case Number: Date Filed Where Filed. Location Case Number Date Filed Where Filed Pending Bankruptcy Case Filed by any Spouse. Partner. or Affiliate of this Debtor (If more than one. attach additional sheet) (To be completed if debtor is required to tile periodic reports forms IOK and IOQ) With the Securities and Exchange Commissron pursuant to Section l3 or l5(d) ol? the Securities Exchange Act of I934 and is requesting relief under chapter I Exhibit A is attached and made a part ofthis petition. Name ol?Dehtor Case Number: Date Filed' District Relationship: Judge Exhibit A Exhibit (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 chapter 7, 1. l2. or I) of title I l, United States Code. a explained the relie vailahlc under each such chapter. I further ccrti ave delivered to the deb the notice required by ll SC. 342(b). M0013 Signature of AttomeNoaDeb'torts) (Date) Yes. and Exhibit is attached and made a pan ol?this petition No. Exhibit 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" If this IS ajornt petition Exhibit (To be completed by every individual debtor If a jomt petition is filed, each spouse must complete and attach a separate Exhibit [2 Exhibit D. completed and signed by the debtor. IS attached and made a pan ol?this petition. Exhibit D. also completed and signed by the joint debtor. is attached and made a part of this petition. Information Regarding the Debtor - Venue (C heck any applicable box of the petition. Debtor has been domiciled or has had a residence. principal place of busrness. or assets in this District for ISO days immediately preceding the date of this petition or for a longer part of such I80 days than in any other District, There is a bankruptcy case concerning debtor?s af?liate, general partner. or partnership pending in this District Debtor IS a debtor in a foreign proceeding and has its prinCipal place of business or assets in the United States in this DistricL or has no principal place of business or assets in the United States but is a defendant in an action or proceeding [in a federal or state court] in this District. or the interests of the parties will he served in regard to the relief sought in this District. Certi?cation by a Debtor Who Resides as a Tenant of Residential Property (Check all applicable boxes Landlord has a judgment against the debtor for possession ol?debtor?s residence. (?box checked. complete the followrng (Name oflandlord 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 with this petition the deposit With the court ofany rent that would become due during the 30-day period after the ?ling Debtor certi?es that he/she has served the Landlord with this certi?cation. (l U.S C. 9? 3620)) a Case 13-13096-MAM Doc 6 Filed 02/12/13 Page 3 of 4 Bl (Of?cial Form 1) (l2/ll) Page 3 Voluntary Petition (This page must be completed and filed in every case.) Name of Debtor(s): Siskind. Jeffrey M. Signatures Signature(s) of Debtor(s) (Individual/Joint) declare under penalty of perqu 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 ?le under chapter 7] i am aware that I may proceed under chapter 7. l. l2 or l3 oftitle l. 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] have obtained and read the notice required by C. 342(b). speCi?ed in this petition 5 Signature of Debtor Si nature ofJoint Debtor 1-832-7720 Tele hone Number (if not represented by attorney) 0 12/201 3 Date Signature of a Foreign Representative I declare under penalty of perjury that the information prowded 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 ?le this petition. (Check only one box I request relief in accordance with chapter l5 oftitle l, United States Code Certi?ed copies ofthe documents required by S.C ISIS are attached [3 Pursuant to II l5] l, I request reliefin accordance with the chapter oftitle I speci?ed in this petition. A certified copy ofthc order granting recognition of the foreign main proceeding IS attached (Signature of Foreign Representative) (Printed Name of Foreign Representative) Date Signature ofAttomey for Debtor?) Jeffrey M. Siskind Printed Name of Attorney for DebtorM\ Siskind Legal Firm Name 525 S. Flagler Drive. Suite 500 West Palm Beach. FL 33401 Address 561-832-7720 Tele hone Number 0 12/2013 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. Signature of Non-Attorney Bankruptcy Petition Preparer I declare under penalty of perjury that: (1)1 am a bankruptcy petition preparer as de?ned in U.S.C. l0; (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 C. ll0(b), ll0(h), and 342(b), and. (3) if rules or guidelines have been promulgated pursuant to SC. l0(h) setting a maxrmum fee for services chargeable by bankruptcy petition preparers, have given the debtor notice ofthc maximum amount before preparing any document for ?ling for a debtor or accepting any fee from the debtor, as required in that section. Of?cral Form [9 is attached. Printed Name and title, ifany. of Bankruptcy Petition Preparer Social-Security number (if the bankruptcy petition preparer 15 not an indivrdual, state the Social-Security number ofthc oiTiccr. prinCIpal, responsible person or partner ofthe petition preparer (Requtred by 1 10 Signature of Debtor (Corporation/Partnership) I declare under penalty of perjury that the information provtded in this petition is true and correct, and that have been authorized to ?le this petition on behalf of the debtor The debtor requests the relief in accordance with the chapter of title I l. United States ode. speci?ed in this petition Signature ofAuthorized individual Printed Name ofAuthorized Individual Title of Authorired lndivrdual Date Address Signature Date Signature of bankruptcy petition preparer or of?cer. princrpal. responsible person. or partner whose Socral-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 if more than one person prepared this document. attach additional sheets conforming to the appropriate of?cial form for each person. A bankruplcy petition preparer '5 failure In comply with the provisions of til/e II and Ihe Federal Rules of Ban/trupley Procedure may result in ?nes or imprisonment or both. II U.S.C. I8 U.S.C. ?156. Case 13-13096-MAM Doc 6 Filed 02/12/13 Page 4 of 4 Exhibit A to Voluntary Petition of Jeffrey Marc Siskind All other names used by Debtor in the last 8 years: Jeffrey M. Siskind Jeffrey Siskind Jeff Siskind TPS (a DBA, formerly a Florida limited liability company) Siskind Legal (3 DBA, formerly a Florida limited liability company)