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Off icial Form 206Sum Summary of Assets and Liabilities for Non-Individuals page 1
Official Form 206Sum Summary of Assets and Liabilities for Non-Individuals 12/15
Part 1: Summary of Assets
1. Schedule A/B: Assets–Real and Personal Property (Official Form 206A/B)
1a. Real property: Copy line 88 from Schedule A/B ..................................................................................................................................... $ ________________
1b. Total personal property: Copy line 91A from Schedule A/B...................................................................................................................................
$ ________________
1c. Total of all property: Copy line 92 from Schedule A/B .....................................................................................................................................
$ ________________
Part 2: Summary of Liabilities
2. Schedule D: Creditors Who Have Claims Secured by Property (Official Form 206D) Copy the total dollar amount listed in Column A, Amount of claim, from line 3 of Schedule D.............................................. $ ________________
3. Schedule E/F: Creditors Who Have Unsecured Claims (Official Form 206E/F)
3a. Total claim amounts of priority unsecured claims: Copy the total claims from Part 1 from line 5a of Schedule E/F .................................................................................... $ ________________
3b. Total amount of claims of nonpriority amount of unsecured claims: Copy the total of the amount of claims from Part 2 from line 5b of Schedule E/F ......................................................... + $ ________________
4. Total liabilities................................................................................................................................................................... Lines 2 + 3a + 3b $ ________________
Debtor name _________________________________________________________________
United States Bankruptcy Court f or the:_______________________ District of ________ (State)
Case number (If known): _________________________
Fill in this information to identify the case:
PEMBROKE HEALTH FACILITIES GP, LLC
NORTHERN DISTRICT TEXAS
18-42696 MXM
0.00
51,817.50
51,817.50
0.00
0.00
X Check if this is an amended filing
38,919,456.57
38,919,456.57
Case 18-42696-mxm11 Doc 18 Filed 09/07/18 Entered 09/07/18 18:03:21 Page 1 of 6
Official Form 206E/F Schedule E/F: Creditors Who Have Unsecured Claims page 1 of ___
Official Form 206E/F
Schedule E/F: Creditors Who Have Unsecured Claims 12/15 Be as complete and accurate as possible. Use Part 1 for creditors with PRIORITY unsecured claims and Part 2 for creditors with NONPRIORITY unsecured claims. List the other party to any executory contracts or unexpired leases that could result in a claim. Also list executory contracts on Schedule A/B: Assets - Real and Personal Property (Official Form 206A/B) and on Schedule G: Executory Contracts and Unexpired Leases (Official Form 206G). Number the entries in Parts 1 and 2 in the boxes on the left. If more space is needed for Part 1 or Part 2, fill out and attach the Additional Page of that Part included in this form.
Part 1: List All Creditors with PRIORITY Unsecured Claims
1. Do any creditors have priority unsecured claims? (See 11 U.S.C. § 507).
No. Go to Part 2.
Yes. Go to line 2.
2. List in alphabetical order all creditors who have unsecured claims that are entitled to priority in whole or in part. If the debtor has more than 3 creditors with priority unsecured claims, fill out and attach the Additional Page of Part 1.
Total claim Priority amount
2.1 Priority creditor’s name and mailing address As of the petition filing date, the claim is: Check all that apply.
Contingent Unliquidated Disputed
$______________________ $_________________ __________________________________________________________________
___________________________________________
___________________________________________
Date or dates debt was incurred
_________________________________
Basis for the claim: __________________________________
Last 4 digits of account number ___ ___ ___ ___
Is the claim subject to offset?
No Yes
Specify Code subsection of PRIORITY unsecured claim: 11 U.S.C. § 507(a) (_____)
2.2 Priority creditor’s name and mailing address As of the petition filing date, the claim is: Check all that apply.
Contingent Unliquidated Disputed
$______________________ $_________________ __________________________________________________________________
___________________________________________
___________________________________________
Date or dates debt was incurred
_________________________________
Basis for the claim: __________________________________
Last 4 digits of account number ___ ___ ___ ___
Is the claim subject to offset?
No Yes
Specify Code subsection of PRIORITY unsecured claim: 11 U.S.C. § 507(a) (_____)
2.3 Priority creditor’s name and mailing address As of the petition filing date, the claim is: Check all that apply.
Contingent Unliquidated Disputed
$______________________ $_________________ __________________________________________________________________
___________________________________________
___________________________________________
Date or dates debt was incurred
_________________________________
Basis for the claim: __________________________________
Last 4 digits of account number ___ ___ ___ ___
Is the claim subject to offset?
No Yes
Specify Code subsection of PRIORITY unsecured claim: 11 U.S.C. § 507(a) (_____)
Debtor __________________________________________________________________
United States Bankruptcy Court for the: ______________________ District of __________ (State)
Case number ___________________________________________ (If known)
Fill in this information to identify the case:
PEMBROKE HEALTH FACILITIES GP, LLC
NORTHERN DISTRICT TEXAS
18-42696
X
3
X Check if this is an amended filing
Case 18-42696-mxm11 Doc 18 Filed 09/07/18 Entered 09/07/18 18:03:21 Page 2 of 6
Debtor _______________________________________________________ Case number (if known)_____________________________________ Name
Official Form 206E/F Schedule E/F: Creditors Who Have Unsecured Claims page __ of ___
Part 2: List All Creditors with NONPRIORITY Unsecured Claims
3. List in alphabetical order all of the creditors with nonpriority unsecured claims. If the debtor has more than 6 creditors with nonpriority unsecured claims, fill out and attach the Additional Page of Part 2.
Amount of claim
3.1 Nonpriority creditor’s name and mailing address As of the petition filing date, the claim is: Check all that apply.
Contingent Unliquidated Disputed
$________________________________ ____________________________________________________________
____________________________________________________________
____________________________________________________________
Basis for the claim: ________________________
Date or dates debt was incurred ___________________
Last 4 digits of account number ___ ___ ___ ___
Is the claim subject to offset?
No Yes
3.2 Nonpriority creditor’s name and mailing address As of the petition filing date, the claim is: Check all that apply.
Contingent Unliquidated Disputed
$________________________________ ____________________________________________________________
____________________________________________________________
____________________________________________________________
Basis for the claim: ________________________
Date or dates debt was incurred ___________________
Last 4 digits of account number ___ ___ ___ ___
Is the claim subject to offset?
No Yes
3.3 Nonpriority creditor’s name and mailing address As of the petition filing date, the claim is: Check all that apply.
Contingent Unliquidated Disputed
$________________________________ ____________________________________________________________
____________________________________________________________
____________________________________________________________
Basis for the claim: ________________________
Date or dates debt was incurred ___________________
Last 4 digits of account number ___ ___ ___ ___
Is the claim subject to offset?
No Yes
3.4 Nonpriority creditor’s name and mailing address As of the petition filing date, the claim is: Check all that apply.
Contingent Unliquidated Disputed
$________________________________ ____________________________________________________________
____________________________________________________________
____________________________________________________________
Basis for the claim: ________________________
Date or dates debt was incurred ___________________
Last 4 digits of account number ___ ___ ___ ___
Is the claim subject to offset?
No Yes
3.5 Nonpriority creditor’s name and mailing address As of the petition filing date, the claim is: Check all that apply.
Contingent Unliquidated Disputed
$________________________________ ____________________________________________________________
____________________________________________________________
____________________________________________________________
Basis for the claim: ________________________
Date or dates debt was incurred ___________________
Last 4 digits of account number ___ ___ ___ ___
Is the claim subject to offset?
No Yes
3.6 Nonpriority creditor’s name and mailing address As of the petition filing date, the claim is: Check all that apply.
Contingent Unliquidated Disputed
$________________________________ ____________________________________________________________
____________________________________________________________
____________________________________________________________
Basis for the claim: ________________________
Date or dates debt was incurred ___________________
Last 4 digits of account number ___ ___ ___ ___
Is the claim subject to offset?
No Yes
WELL FARGO BANK, N.A.35,478,745.03
FSF DIP, LLC161,376.00
X
X
5500 W. PLANO PARKWAY, SUITE 201
PLANO, TX 75093
SEE ATTACHED SCHEDULE E
X
PEMBROKE HEALTH FACILITIES GP, LLC 18-42696
2 3
3,279,335.54
Case 18-42696-mxm11 Doc 18 Filed 09/07/18 Entered 09/07/18 18:03:21 Page 3 of 6
Debtor _______________________________________________________ Case number (if known)_____________________________________ Name
Official Form 206E/F Schedule E/F: Creditors Who Have Unsecured Claims page __ of ___
Part 4: Total Amounts of the Priority and Nonpriority Unsecured Claims
5. Add the amounts of priority and nonpriority unsecured claims.
Total of claim amounts
5a. Total claims from Part 1 5a. $_____________________________
5b. Total claims from Part 2
5b. + $_____________________________
5c. Total of Parts 1 and 2
Lines 5a + 5b = 5c. 5c. $_____________________________
PEMBROKE HEALTH FACILITIES GP, LLC 18-42696
0.00
3 3
38,919,456.47
38,919,456.57
Case 18-42696-mxm11 Doc 18 Filed 09/07/18 Entered 09/07/18 18:03:21 Page 4 of 6
Schedule E/F3. List All Creditors with NONPRIORITY Unsecured Claims
Line
Num
ber
Creditor Name Address Basis for Claim Con
tinge
nt
Unl
iqui
date
d
Dis
pute
d
Claim Amount3.1 ANNA HOUCHENS ADDRESS REDACTED ACCRUED VACATION/PTO X $412.80
3.2 APRIL R POLSTON ADDRESS REDACTED ACCRUED VACATION/PTO X $47.23
3.3 ASHLEY N WEST ADDRESS REDACTED ACCRUED VACATION/PTO X $49.74
3.4 AUDREY J FOWLER ADDRESS REDACTED ACCRUED VACATION/PTO X $344.65
3.5 BENJAMIN J ROBINSON ADDRESS REDACTED ACCRUED VACATION/PTO X $361.30
3.6 CARESOURCE PROGRAMS 2200 6TH AVE SUITE 833, SEATTLE, WA 98121 TRADE $299.00
3.7 CASS INFORMATION SYSTEM INC CIS#92012, PO BOX 17617, ST. LOUIS, MO 63178 TRADE $270.00
3.8 CLOTILDA ROBINSON ADDRESS REDACTED ACCRUED VACATION/PTO X $173.49
3.9 CONFIDENTIAL PATIENT REFUND $3,613.86
3.10 CONFIDENTIAL PATIENT REFUND $966.00
3.1 CONFIDENTIAL PATIENT REFUND $1,246.00
3.12 CONFIDENTIAL PATIENT REFUND $1,255.33
3.1 CONFIDENTIAL PATIENT REFUND $322.00
3.14 CONFIDENTIAL PATIENT REFUND $2,246.27
3.2 CORINNA M GREENFIELD ADDRESS REDACTED ACCRUED VACATION/PTO X $1,900.89
3.16 CRYSTAL D HOLLAND ADDRESS REDACTED ACCRUED VACATION/PTO X $288.07
3.2 DIRECT SUPPLY PO BOX 88201, MILWAUKEE, WI 53288 TRADE $1,711.69
3.18 DOROTHY KELLER ADDRESS REDACTED ACCRUED VACATION/PTO X $220.84
3.2 DOROTHY KELLER ADDRESS REDACTED WORKERS COMP X X X UNLIQUIDATED
3.20 FAAILOA BUSSELL ADDRESS REDACTED ACCRUED VACATION/PTO X $461.11
3.2 FACILITY SUPPORT FUNDING LLC 5420 W PLANO PKWY, PLANO, TX 75093 INTERCOMPANY $3,082,575.00
3.22 FEDERAL EXPRESS COPRORATION PO BOX 371461, PITTSBURGH, PA 15250 TRADE $46.99
3.2 FIRST CHOICE MEDICAL SUPPLY HOLDING INC PO BOX 3608, JACKSON, MS 39207 TRADE $10,593.98
3.24 FRANK GREER ADDRESS REDACTED EXPENSE REIMBURSEMENT X $130.00
3.3 HD SUPPLY FACILITIES MAINTENANCE LTD PO BOX 509058, SAN DIEGO, CA 92150 TRADE $146.08
3.26 HEALTHCARE SERVICES GROUP 3220 TILLMAN DRIVE, SUITE 300, BENSALEM, PA 19020 TRADE $63,945.85
3.3 IESHIA A MANSON ADDRESS REDACTED ACCRUED VACATION/PTO X $67.51
3.28 IRON MOUNTAIN INC, PO BOX 915004, DALLAS, TX 75391 TRADE $274.40
3.3 JENNIE STUART MEDICAL CENTER 320 WEST 18TH STREET, PO BOX 2400, HOPKINVILLE, KY 42241 TRADE $537.62
3.30 JOERNS WOUNDCO HOLDINGS INC KEYBANK-LCKBOX 713222, 895 CENTRAL AVENUE, CINCINNATI, OH 45202 TRADE -$584.83
3.3 KAETA F MONTGOMERY ADDRESS REDACTED ACCRUED VACATION/PTO X $63.96
3.32 KAREN U WOODS ADDRESS REDACTED ACCRUED VACATION/PTO X $194.28
3.3 KENTUCKY ASSOC OF HEALTHCARE FACILITIES DEPT #52200, PO BOX 950174, LOUISVILLE, KY 40295 TRADE $110.00
3.34 KENTUCKY STATE TREASURER (PROVIDER TAXES) KENTUCKY DEPARTMENT OF REVENUE, FRANKFORT, KY 40620 TRADE $14,918.85
3.4 KIMBERLY K FRASIER ADDRESS REDACTED ACCRUED VACATION/PTO X $142.47
3.36 KONICA MINOLTA BUSINESS SOLUTIONS USA INC, DEPT. CH 19188, PALATINE, IL 60055 TRADE $70.03
3.4 LAKEYSA C SMITH ADDRESS REDACTED ACCRUED VACATION/PTO X $675.42
3.38 LAVORISE WILLIAMS ADDRESS REDACTED ACCRUED VACATION/PTO X $407.77
3.4 LISA M CARTWRIGHT ADDRESS REDACTED ACCRUED VACATION/PTO X $468.76
3.40 MED-PASS INC L-3495, COLUMBUS, OH 43260 TRADE $93.87
3.4
NANCY FORD AND TAMMY JONES AS
ADMINISTRATORS OF THE ESTATE OF ONDICE FORDLITIGATION X X X UNLIQUIDATED
3.42 NATASHA JOHNSON ADDRESS REDACTED ACCRUED VACATION/PTO X $331.90
3.4 NATIONAL DATACARE CORPORATION PO BOX 222430, CHANTILLY, VA 20153 TRADE $109.05
3.44 O.C. TANNER COMPANY 1930 SOUTH STATE STREET, SALT LAKE CITY, UT 84115 TRADE $255.92
3.4 ON HOLD MARKETING SERVICES 6840 WEST 70TH STREET, SHREVEPORT, LA 71129 TRADE $37.95
3.46 PHARMACY CORPORATION OF AMERICA ATTN: MIKE RODRIGUEZ, 1900 S SUNSET UNIT 1A, LONGMONT, CO 80501 TRADE $30,448.71
3.5 PINCOMPUTING COMPANY LP 5500 W. PLANO PKWY SUITE 210, PLANO, TX 75093 TRADE $1,350.00
3.48 PORTER ONE DESIGN 37680 HILLS TECH DRIVE, FARMINGTON HILLS, MI 48331 TRADE $167.90
3.5 QUINTAIROS,PRIETO,WOOD & BOYER,P.A. 9300 S. DADELAND BLVD., 4TH FLOOR, MIAMI, FL 33156 TRADE $2,837.50
3.50 RELIANT REHABILITATION PO BOX 671181, DALLAS, TX 75267 TRADE $28,374.44
3.5
SANDRA MCGREGOR, AS ADMINISTRATRIX OF THE
ESTATE OF LILLIAN MCGREGOR LITIGATION X X X UNLIQUIDATED
3.52 SARAH E MAPPS ADDRESS REDACTED ACCRUED VACATION/PTO X $1,030.27
3.5 SILVER SWAN ASSISTED TRANSPORT LLC 104 FENTON COURT, HOPKINSVILLE, KY 42240 TRADE $3,240.00
3.54 SPECIALIZED MEDICAL SERVICES INC 7237 SOLUTION CENTER, CHICAGO, IL 60677 TRADE $1,982.10
3.5 STAPLES CONTRACT & COMMERCIAL INC DEPT DAL, PO BOX 83689, CHICAGO, IL 60696 TRADE $450.96
3.56 STEPHANIE ADAMS ADDRESS REDACTED ACCRUED VACATION/PTO X $985.81
3.6 STEPHANIE HOUCHENS ADDRESS REDACTED EXPENSE REIMBURSEMENT X $528.36
3.58 SYMPHONY DIAGNOSTIC SERVICES NO 1 INC PO BOX 17462, BALTIMORE, MD 21297 TRADE $80.00
3.6 TAMMY J WORKMAN ADDRESS REDACTED ACCRUED VACATION/PTO X $3,635.38
3.60 TAMMY WORKMAN ADDRESS REDACTED DEFERRED COMPENSATION X $5,322.85
3.6 TANIKA L BRADFORD ADDRESS REDACTED ACCRUED VACATION/PTO X $1,323.84
3.62 TAYLOR CORPOATION PO BOX 840655, DALLAS, TX 75284 TRADE $26.12
3.6 TIFFANY J SANDERS ADDRESS REDACTED ACCRUED VACATION/PTO X $318.85
3.64
TONYA FRANCIES, AS ADMINISTRATRIX OF THE
ESTATE OF GLENDA OLIVER, DECEASED, AND ON
BEHALF OF THE WRONGFUL DEATH BENEFICIARIES
OF GLENDA OLIVER
JACQUES BALETTE AND JULIETTE BALETTE-SYMONS OF MARKS, BALETTE
& GIESSEL GIESSEL & YOUNG, P.L.L.C., 7521 WESTVIEW DR., HOUSTON,
TEXAS 77055 LITIGATION X X X UNLIQUIDATED
3.6 TONYA SYMPSON ADDRESS REDACTED WORKERS COMP X X X UNLIQUIDATED
3.66 VANGUARD SALES OF EVANSVILLE INC 816 MAXWELL AVE, EVANSVILLE, IN 47711 TRADE $75.26
3.7 VENILIA J SMITH ADDRESS REDACTED ACCRUED VACATION/PTO X $969.05
3.68 WILBERT H FREELAND ADDRESS REDACTED ACCRUED VACATION/PTO X $1,342.54
3.7
WILLIAM SIMON, AS ADMINISTRATOR OF THE
ESTATE OF SARAH BLACK
BRIAN JASPER, WILKES & MCHUGH, PA, 429 N. BROADWAY, LEXINGTON, KY
40508 LITIGATION X X X UNLIQUIDATED
3.70 WILSON, ELSER, MOSKOWITZ, EDELMAN 150 EAST 42ND STREET, NEW YORK, NY 10017 TRADE $3,042.50
$3,279,335.54TOTAL:
Pembroke Health Facilities, L.P.
ScheduleF - SCHEDULE F
Case 18-42696-mxm11 Doc 18 Filed 09/07/18 Entered 09/07/18 18:03:21 Page 5 of 6
Case 18-42696-mxm11 Doc 18 Filed 09/07/18 Entered 09/07/18 18:03:21 Page 6 of 6
