Exhibit A
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Exhibit A Form. This is a Official Federal Forms form and can be use in General Bankruptcy.
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Tags: Exhibit A, B1, Official Federal Forms Bankruptcy, General
B 1A (Official Form 1, Exhibit A) (9/97)
[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 of the Bankruptcy Code, this
Exhibit “A” shall be completed and attached to the petition.]
UNITED STATES BANKRUPTCY COURT
__________ District of __________
In re
,
)
Debtor
Case No.
)
)
)
Chapter 11
EXHIBIT “A” TO VOLUNTARY PETITION
1. If any of the debtor’s securities are registered under Section 12 of the Securities Exchange Act of 1934, the
SEC file number is
.
2. The following financial data is the latest available information and refers to the debtor’s condition on
.
a. Total assets
$
b. Total debts (including debts listed in 2.c., below)
$
c. Debt securities held by more than 500 holders:
Approximate
number of
holders:
secured
’
unsecured ’
subordinated ’
$
secured
’
unsecured ’
subordinated ’
$
secured
’
unsecured ’
subordinated ’
$
secured
’
unsecured ’
subordinated ’
$
secured
’
unsecured ’
subordinated ’
$
d. Number of shares of preferred stock
e. Number of shares common stock
Comments, if any:
3. Brief description of debtor’s business:
4. List the names of any person who directly or indirectly owns, controls, or holds, with power to vote, 5% or
more of the voting securities of debtor:
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