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EARP & ASSOCIATES, P.C. ATTORNEYS AND COUNSELORS AT LAW 302 Walnut Street Bowie, TX 76230 Phone: 940-872-8500 Fax: 940-872-8502
BANKRUPTCY QUESTIONNAIRE FOR NON-BUSINESS DEBTOR PLEASE FILL OUT USING ALL AVAILABLE CURRENT AND ACCURATE INFORMATION ----------------------------------------------------------------------Failure to provide current and accurate information on these forms makes it very difficult to provide service to you as a bankruptcy client of our firm. The Bankruptcy Courts of the United States require absolutely accurate reflections of all debts, obligations and information regarding you, and when appropriate, your failure to provide this information may result in your bankruptcy case being dismissed and your fee forfeited.
UPON COMPLETION PLEASE CALL THE STAFF OF THE LAW OFFICES OF BRANDON S. EARP, P.C., AT THE ABOVE NUMBER TO MAKE AN APPOINTMENT TO REVIEW THE INFORMATION AND BEGIN PREPARATION OF YOUR BANKRUPTCY FILINGS
Section 1 ~ Basic Information Part A. Name and Address Name: ________________________________________________________________ Last First Middle Telephone Number
Home: ______________________ Work: __________________
Have you used any other names in the past six years? 9No 9Yes If yes, list other names:_____________________________________________ Social Security Number: ______ - _____ - ______ Address:
__________________________________________________________
City:
_____________________ State: ________________ Zip: ___________
County:
_____________________
Have you lived at this address for at least 180 days? 9No 9Yes If you have a different mailing address, please list: Mailing address: __________________________________________________ City: ________________________ State: ____________ Zip: ____________ Part B. Name and Address of Spouse If you are filing jointly with your spouse, fill in the following information about your spouse: Name: ________________________________________________________________ Last First Middle Telephone Number
Home: ______________________ Work: __________________
Has your spouse used any other names in the past six years? 9No 9Yes If yes, list other names:_____________________________________________ Social Security Number: ______ - _____ - ______ Address: (if different from your address):
__________________________________
City:
_____________________ State: ________________ Zip: ___________
County:
_____________________
If your spouse has a different mailing address, please list: Mailing address: __________________________________________________
City: ________________________ State: ____________ Zip: ____________ Part C. Prior/Pending Bankruptcy Cases Has a bankruptcy case been filed by you or against you in the last 6 years? 9 No 9Yes If yes, in which district of which state was the case filed? ______________________ Case Number: ______________________ Date filed: _______________________ Are there currently any bankruptcy cases pending against you, your business, your spouse, or your spouse’s business? 9 No 9 Yes If yes, name of debtor: ________________________________ Relationship to you: __________________________________ Case Number: _____________________ Date filed: ________ Judge: _____________ In which district of which state was the case filed? _____________________________
Section 2 ~ Property Part A. Real Estate (Schedule A) List all real estate which you own or are a joint owner of, even if you still owe money on the property. Address and Description of Property
Owned by Husband, Wife, Joint or Community
Market Value
Your % Ownership, or $ amount, if you and spouse are not sole owners
List mortgages, home equity loans, and any other liens
Office Use Only
What is the $ value of the loan, lien or mortgage?
Exemptions ?
Who issued the lien, loan or mortgage?
Part B. Personal Property (Schedule B) For each type of property listed below, indicate whether you own any property of that category, and, if you do, fill in the remaining information. You can think of the market value as the resale value at an auction or garage sale. Type of Property
Yes/No?
Description & Location
Husband, Wife, Joint, Community?
Market Value
Office Use Only Exemptions?
1. Cash on Hand 2. Checking/Savings Account, Certificates of Deposit, other bank accounts
3. Security deposits held by utility companies, landlord 4. Household goods, furniture, including audio, video, and computer equipment
Type of Property
Yes/No?
Description & Location
Husband, Wife, Joint, Community?
Market Value
Office Use Only Exemptions?
5. Books, pictures, art objects, records, compact discs, collectibles 6. Clothing 7. Furs and jewelry 8. Sports, photographic, hobby equipment, firearms 9. Interest in insurance policiesspecify refund or cancellation value 10. Annuities 11. Interests in pension or profit sharing plans
12. Stock and interests in incorporated/unincorp orated business
Type of Property
Yes/No?
Description & Location
Husband, Wife, Joint, Community?
Market Value
Office Use Only Exemptions?
13. Interests in partnerships/joint ventures 14. Bonds 15. Accounts receivable 16. Alimony/family support to which you are entitled 17. Other liquidated debts owed to you, including tax refunds 18. Equitable or future interest or life estates 19. Interests in estate of descendent or life insurance plan or trust 20. Other contingent/ unliquidated claims, including lawsuits and counterclaims 21. Patents, copyrights, other intellectual property 22. Licenses, franchises
Type of Property
Yes/No?
Description & Location
Husband, Wife, Joint, Community?
Market Value
Office Use Only Exemptions?
23. Automobiles, trucks, trailers, and accessories
24. Boats, motors and accessories 25. Aircraft and accessories 26. Office equipment, supplies 27. Machinery, fixtures etc. for business 28. Inventory
29. Animals
30. Crops 31. Farming equipment 32. Farm supplies, chemicals, feed
Type of Property
Yes/No?
Description & Location
Husband, Wife, Joint, Community?
Market Value
Office Use Only Exemptions?
33. Other personal property of any kind not listed elsewhere.
Section 3 ~ Debts List below all debts that you owe, or that creditors claim that you owe. Type of Debt
Home loans/ mortgages Car loans Other bank loans Personal loans Student loans Major credit card debts (Visa, AmEx, Mastercard, Discover) continue on next page if necessary
Creditor Name and Address, Account Number, if any Date/range of dates when debt was incurred
Amount owed
Name and address of codebtor, if any What is debt for? Is debt secured by any property?
Do you dispute the debt?
OFFICE USE ONLY Lawsuit pending? Collection agency Sched. assigned? D,E or Counsel for F? creditor?
Type of Debt
Major credit card debts (Visa, AmEx, Mastercard, Discover) continued
Department store credit card debts
Other credit card debts (gas, phone cards, etc.)
Creditor Name and Address, Account Number, if any Date/range of dates when debt was incurred
Amount owed
Name and address of codebtor, if any What is debt for? Is debt secured by any property?
Do you dispute the debt?
OFFICE USE ONLY Lawsuit pending? Collection agency Sched. assigned? D,E or Counsel for F? creditor?
Type of Debt
Unpaid medical bills
Unpaid utility bills
Unpaid rent
Unpaid taxes
Creditor Name and Address, Account Number, if any Date/range of dates when debt was incurred
Amount owed
Name and address of codebtor, if any What is debt for? Is debt secured by any property?
Do you dispute the debt?
OFFICE USE ONLY Lawsuit pending? Collection agency Sched. assigned? D,E or Counsel for F? creditor?
Type of Debt
Unpaid alimony or child support
Unpaid service fees
All other unpaid debts/ bills
Creditor Name and Address, Account Number, if any Date/range of dates when debt was incurred
Amount owed
Name and address of codebtor, if any What is debt for? Is debt secured by any property?
Do you dispute the debt?
OFFICE USE ONLY Lawsuit pending? Collection agency Sched. assigned? D,E or Counsel for F? creditor?
Section 4 ~ Unexpired Leases and Contracts (Schedule G) List below any leases or contracts that are still current that you are a party to. Include residential, car and business leases, and service and business contracts. Nature and Description of Contract
Name and Address of Other Party or Parties
Date that Contract Expires
Section 5 ~ Current Income Marital Status: 9 Married 9 Single 9 Divorced 9 Separated 9 Widowed
List all dependents of you and your spouse, their ages, and relationship to you: ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________
Part A. Debtor’s Income 1. What is your occupation? ___________ 2. Name and address of your employer: ________________________________ ________________________________ ________________________________
Part B. Joint Debtor’s Income 1. What is you spouse’s occupation? ____________ 2. Name and address of you spouse’s employer: ________________________________________ ________________________________________ ________________________________________
3. How long have you been employed there? ________________________________ 4. What is the gross amount of your paycheck, before taxes, other deductions are taken out? $_________ 5. How often do you get paid? ______________ 6. Do you receive overtime pay outside of your salary? _____ If so, how much per month? __________________ 7. How much is taken out of each paycheck for taxes and social security ? $_______________ 8. How much is taken out for insurance? $_________ 9. How much for union dues? $_________ 10. Are there other deductions? If so, what are they and how much? ___________________________
3. How long employed there? __________________ 4. What is the gross amount of your spouse’s paycheck, before taxes/other deductions? $____________ 5. How often does your spouse get paid? __________ 6. Does you spouse receive overtime pay outside of your salary? ___________ If so, how much per month? ___________________ 7. How much is taken out of each paycheck for taxes and social security? $________________ 8. How much is taken out for insurance? $___________ 9. How much for union dues? $_______________ 10. Are there other deductions? If so, what are they and how much? ___________________________________
Do you receive.... a) income from business operations outside of your regular paycheck listed above? If so, what is the Business and how much do you receive per month? ____________________________________
Does your spouse receive ..... a) income from business operations outside of the regular paycheck listed above? If so, what is the business and how much does your spouse receive per month? ______________________________________________
b) income from real estate property? If so, how b) income from real estate property? If so, how much per much per month? __________________________ month? ________________________________________ c) interest or dividends? If so, how much per month? ________________________________________
c) interest or dividends? If so, how much per month? _______________________________________________
d) alimony or family support payments for your use for the care of your dependents? If so, how much per month? _______________________________
d) alimony or family support payments for spouse’s use or for care of dependents? If so, how much per month? _______________________________________________
e) social security or other forms of monetary government assistance? ____________________
e) social security or other forms of monetary government assistance? _____________________________________
f) retirement or pension money? _______________ Do you have any other sources of income not listed? ______________________
f) retirement or pension money? _____________________ Does your spouse have any other income not listed? _________________________
Are you or your spouse expecting any increase or decrease in salary of more than 10% in the next year? If so, explain.
______________________________________________________________________________________
Section 6 ~ Current Expenses Do you and your spouse maintain separate households? your household and another for your spouse’s.
G No G Yes
If so, fill one page out for
The following questions ask for your expenses each month. If you are unsure of the amount you pay each month, but know the amount for a different period (per week, per day, every 2 months, etc.), write in the amount and the frequency that you pay the amount. Indicate how much you pay for each item each month.... 1. Your rent or your home mortgage $_____________________________ Does that amount include real estate taxes? G No GYes Does that amount include property insurance? G No G Yes 2. Electricity $_____________________________ 3. Natural gas or propane $_____________________________ 4. Water and sewage $_____________________________ 5. Telephone service, including long distance $_____________________________ 6. Do you have any other utility bills? If so, what, and how much per month? ____________________________________________ $_____________________________ ____________________________________________ $_____________________________ 7. Home maintenance, including repairs and general upkeep $_____________________________ 8. Food $_____________________________ 9. Clothing $_____________________________ 10. Laundry and dry cleaning $_______________________ ______ 11. Transportation (not including car payments) $_____________________________ 12. Entertainment, recreation, newspapers, magazines $_____________________________ 13. Charitable contributions $_____________________________ 14. Insurance not deducted from paycheck a) Homeowner’s or renter’s insurance $_____________________________ b) Life insurance $_____________________________ c) Health insurance $_____________________________ d) Auto insurance $_____________________________ e) Other insurance __________________________ $_____________________________ 15. Taxes not deducted from paycheck $_____________________________ 16. Installment payments for car, furniture, etc. (Specify) ____________________________________________ $_____________________________ ____________________________________________ $_____________________________ 17. Alimony, maintenance, support paid to others $_____________________________ 18. Payments for support of dependents not living at home $_____________________________ 19. Expenses for operation of business $_____________________________ 20. Medical and dental expenses $_____________________________ 21. Other expenses not otherwise listed ____________________________________________ $_____________________________ ____________________________________________ $_____________________________ ____________________________________________ $_____________________________
Section 7 ~ Statement of Financial Affairs If you are filing jointly with your spouse, include information about you and your spouse. If you are filing under chapter 12 or 13, and you are married and not separated, you must provide information about your spouse even if you are not filing jointly. If you have no information to report for a question, check the “NONE” box. 1. Income from employment or operation of business State your gross income from employment or operation of a business: If you have not received an income from employment during the two years immediately preceding this calendar year, check this box: G NONE Period
$Amount
Source
Husband/Wife
January 1 of this year through date of commencement of case
Last year, (January 1- December 31)
The year before last, (January 1- December 31)
2. Income other than from employment or operation of business State the amount of income received other than from employment or operation of business during the two years immediately preceding the commencement of this case: GNONE Period
$Amount
Source
Husband/Wife
During the last year
Year before last
3. Payments to creditors a.) List all payments on loans, installment purchases of goods or services, and other debts, aggregating more than $600 to any creditor made within 90 days immediately preceding the commencement of this case. GNONE Name and Address of Creditor
Dates of Payments
Amount Paid
Amount still owed
b.) List all payments made within one year immediately preceding the commencement of this case ro creditors who were (“Insiders” include you relatives, your business partners and their relatives, your corporations, or your affiliates.) GNONE Name and Address of Creditor and Relationship to you Dates of Payments Amount Paid Amount Still Owed
4. Suits, executions, garnishments and attachments a.) List all suits and administrative proceedings to which you are or were a party within one year preceding the filing of this case. GNONE Case of Suit and Case Number
Nature of Preceding
Court or Agency and Location
Status or Disposition
b.) Describe all property that has been garnished, seized, or attached under any legal or equitable process within one year immediately preceding the commencement of this case. GNONE Name and Address of Person/Company for Whom the Property Was Seized/(Creditor)
Date of Seizure
Description and Value of Property
5. Repossessions, foreclosures, and returns List all property that a 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. GNONE Name and Address of Creditor
6. Assignments and receiverships
Date of Repossession, Foreclosure, Transfer or Return
Description and Value of Property
a.) Describe any assignment of property for the benefits of creditors made within 120 days immediately preceding the commencement of this case. GNONE Name and Address of Assignee
Date of Assignment
Terms of Assignment/Settlement
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. GNONE Name and Address of Custodian
Name and location of Court , Case Title and Number
Date of Order
Description and Value of Property
7. Gifts 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 aggregating less than $100 per recipient. GNONE Name and Address of Recipient
Relationship to You, if any
Date of gift
Description and Value of Gift
8. Losses List all losses from fire, theft, gambling or other casualty within one year immediately preceding the commencement of this case or since the commencement of this case. GNONE Description and Value of Property
Description of Circumstances and Amount Covered by Insurance, if any
Date of Loss
9. Payments related to debt counseling or bankruptcy List all payments made or property transferred by or on behalf of the debtor to any persons, including attorneys
for consultation concerning debt consultation, relief under the bankruptcy law or preparation of the petition in bankruptcy within one year preceding the commencement of the case. GNONE Name and Address of Payee
Date of Payment
Name of Person Who paid, if not You
Amount of Money/Description and Value of Property
10. Other transfers, (including sale of your property) List all other property, other than the property transferred in your ordinary course or financial affairs, transferred either absolutely or as a security within one year immediately preceding the commencement of this case. GNONE Name and Address of Transferee and Relationship to you
Date of Transfer
Description of Property Transferred and Value Received
11. Closed financial accounts List all financial accounts and instruments held in your name or for your benefit which were closed, sold, or otherwise transferred within one year immediately preceding the commencement of this case. GNONE Name and Address of Institution
Type and Number of Accounts & Final Balance
Amount and Date of Sale or Closing
12. Safe deposit boxes List each safe deposit or other box or depository in which you have or have had securities, cash, or other valuables within one year immediately preceding the commencement of this case. GNONE Name and Address of Bank or other Depository
13. Setoffs
Name and Address of Those With Access to Box or Depository
Description Of Contents
Date of Transfer, if any
List all setoffs made by any creditor, including a bank, against a debt or deposit of yours within 90 days preceding the commencement of this case. GNONE Name and Address of Creditor
Date of Setoff
Amount of Setoff
14. Property held for another person List all property that you hold or control this is owed by another person. GNONE Name and Address of Owner
Description and Value of Property
Location of Property
15. Prior address of debtor If you have moved within the two years immediately preceding the commencement of this case, list all residences during the last two years, excluding your present address. GNONE Address
Your name at the Time
Date of Occupancy
The following questions, #16-21 are only to be answered if you are a corporation or partnership or if you have been, in the two years immediately preceding this case, an officer, director, managing executive, or owner of more than 5% of the voting securities of the corporation; a partner, other than a limited partner, of a partnership, a sole proprietor, or otherwise self-employed. 16. Nature, location and name of business in which you were an officer, director, managing executive, or owner of more than 5% or more of voting or equity securities within the two years immediately preceding the commencement of this case. GNONE Name and Address
Nature of Business
17. Books, records, and financial statements
Dates of Operation-Beginning and End
a.) List all bookkeepers and accountants who, within the six years immediately preceding the filing of this bankruptcy case, kept or supervised the keeping of books of accounts and records. GNONE Name and Address
Dates Services Rendered
b.) List all firms or individuals who, within the two years immediately preceding the filing of this bankruptcy, have audited the books of account and records, or preparing a financial statement of the debtor. GNONE Name and Address
Dates Services Rendered
c.) List all firms or individuals who, all the time of the commencement of this case, were in possession of your books of account and records. If the records are not available, explain. GNONE Name and Address
Comments
d.) List all financial institutions, creditors and other parties, including mercantile and trade agencies, to whom a financial statement was issued by the debtor within two years immediately preceding the commencement of this case. GNONE Name and Address
Date Issued
18. Inventories a.) List the dates of the last two inventories taken of your property, the name of the person who supervised the taking of each inventory, and the dollar amount and basis of each inventory. GNONE Date of Inventory
Inventory Supervisor
Dollar Amount of Inventory (Specify cost, market, or other basis)
b.) List the name and address of the person possessing the records of each of the two inventories reported. GNONE
Date of Inventory
Name and Address of Custodian of Inventory Records
19. Current partners, officers, directors, and shareholders a.) If your business is a partnership, list the nature and percentage of partnership interest of each member of the partnership. GNONE Name and Address
Nature and Percentage of Interest
b.) If your business is a corporation, list all officers and directors of the corporation, and each stockholder who directly owns, controls, or holds 5% or more of the voting securities of the corporation. GNONE Nature and Percentage Name and Address
Title
of Stock Ownership
20. Former partners, officers, directors, and shareholders a.) If your business is a partnership, list each member who withdrew from the partnership within one year immediately preceding the commencement of this case. GNONE Name and Address
Date of Withdrawal
b.) If your business is a corporation, list all officers or directors whose relationship with the corporation terminated within one year immediately preceding the commencement of this case. GNONE Name and Address
Title
Date of Termination
21. Withdrawals from a partnership or distributions by a corporation If your business is a partnership or corporation, list all withdrawals or distributions credited or given to an insider, including compensation in any form, bonuses, loans, stock redemptions, options exercised and any other perquisite during one year preceding the commencement of this case. GNONE Name and Address of Property
Date and Purpose Recipient and Relationship to You
Amount of Money or Description of Withdrawal and Value of
BANKRUPTCY QUESTIONNAIRE FOR NON-BUSINESS DEBTOR PLEASE FILL OUT USING ALL AVAILABLE CURRENT AND ACCURATE INFORMATION ----------------------------------------------------------------------Failure to provide current and accurate information on these forms makes it very difficult to provide service to you as a bankruptcy client of our firm. The Bankruptcy Courts of the United States require absolutely accurate reflections of all debts, obligations and information regarding you, and when appropriate, your failure to provide this information may result in your bankruptcy case being dismissed and your fee forfeited.
UPON COMPLETION PLEASE CALL THE STAFF OF THE LAW OFFICES OF BRANDON S. EARP, P.C., AT THE ABOVE NUMBER TO MAKE AN APPOINTMENT TO REVIEW THE INFORMATION AND BEGIN PREPARATION OF YOUR BANKRUPTCY FILINGS
Section 1 ~ Basic Information Part A. Name and Address Name: ________________________________________________________________ Last First Middle Telephone Number
Home: ______________________ Work: __________________
Have you used any other names in the past six years? 9No 9Yes If yes, list other names:_____________________________________________ Social Security Number: ______ - _____ - ______ Address:
__________________________________________________________
City:
_____________________ State: ________________ Zip: ___________
County:
_____________________
Have you lived at this address for at least 180 days? 9No 9Yes If you have a different mailing address, please list: Mailing address: __________________________________________________ City: ________________________ State: ____________ Zip: ____________ Part B. Name and Address of Spouse If you are filing jointly with your spouse, fill in the following information about your spouse: Name: ________________________________________________________________ Last First Middle Telephone Number
Home: ______________________ Work: __________________
Has your spouse used any other names in the past six years? 9No 9Yes If yes, list other names:_____________________________________________ Social Security Number: ______ - _____ - ______ Address: (if different from your address):
__________________________________
City:
_____________________ State: ________________ Zip: ___________
County:
_____________________
If your spouse has a different mailing address, please list: Mailing address: __________________________________________________
City: ________________________ State: ____________ Zip: ____________ Part C. Prior/Pending Bankruptcy Cases Has a bankruptcy case been filed by you or against you in the last 6 years? 9 No 9Yes If yes, in which district of which state was the case filed? ______________________ Case Number: ______________________ Date filed: _______________________ Are there currently any bankruptcy cases pending against you, your business, your spouse, or your spouse’s business? 9 No 9 Yes If yes, name of debtor: ________________________________ Relationship to you: __________________________________ Case Number: _____________________ Date filed: ________ Judge: _____________ In which district of which state was the case filed? _____________________________
Section 2 ~ Property Part A. Real Estate (Schedule A) List all real estate which you own or are a joint owner of, even if you still owe money on the property. Address and Description of Property
Owned by Husband, Wife, Joint or Community
Market Value
Your % Ownership, or $ amount, if you and spouse are not sole owners
List mortgages, home equity loans, and any other liens
Office Use Only
What is the $ value of the loan, lien or mortgage?
Exemptions ?
Who issued the lien, loan or mortgage?
Part B. Personal Property (Schedule B) For each type of property listed below, indicate whether you own any property of that category, and, if you do, fill in the remaining information. You can think of the market value as the resale value at an auction or garage sale. Type of Property
Yes/No?
Description & Location
Husband, Wife, Joint, Community?
Market Value
Office Use Only Exemptions?
1. Cash on Hand 2. Checking/Savings Account, Certificates of Deposit, other bank accounts
3. Security deposits held by utility companies, landlord 4. Household goods, furniture, including audio, video, and computer equipment
Type of Property
Yes/No?
Description & Location
Husband, Wife, Joint, Community?
Market Value
Office Use Only Exemptions?
5. Books, pictures, art objects, records, compact discs, collectibles 6. Clothing 7. Furs and jewelry 8. Sports, photographic, hobby equipment, firearms 9. Interest in insurance policiesspecify refund or cancellation value 10. Annuities 11. Interests in pension or profit sharing plans
12. Stock and interests in incorporated/unincorp orated business
Type of Property
Yes/No?
Description & Location
Husband, Wife, Joint, Community?
Market Value
Office Use Only Exemptions?
13. Interests in partnerships/joint ventures 14. Bonds 15. Accounts receivable 16. Alimony/family support to which you are entitled 17. Other liquidated debts owed to you, including tax refunds 18. Equitable or future interest or life estates 19. Interests in estate of descendent or life insurance plan or trust 20. Other contingent/ unliquidated claims, including lawsuits and counterclaims 21. Patents, copyrights, other intellectual property 22. Licenses, franchises
Type of Property
Yes/No?
Description & Location
Husband, Wife, Joint, Community?
Market Value
Office Use Only Exemptions?
23. Automobiles, trucks, trailers, and accessories
24. Boats, motors and accessories 25. Aircraft and accessories 26. Office equipment, supplies 27. Machinery, fixtures etc. for business 28. Inventory
29. Animals
30. Crops 31. Farming equipment 32. Farm supplies, chemicals, feed
Type of Property
Yes/No?
Description & Location
Husband, Wife, Joint, Community?
Market Value
Office Use Only Exemptions?
33. Other personal property of any kind not listed elsewhere.
Section 3 ~ Debts List below all debts that you owe, or that creditors claim that you owe. Type of Debt
Home loans/ mortgages Car loans Other bank loans Personal loans Student loans Major credit card debts (Visa, AmEx, Mastercard, Discover) continue on next page if necessary
Creditor Name and Address, Account Number, if any Date/range of dates when debt was incurred
Amount owed
Name and address of codebtor, if any What is debt for? Is debt secured by any property?
Do you dispute the debt?
OFFICE USE ONLY Lawsuit pending? Collection agency Sched. assigned? D,E or Counsel for F? creditor?
Type of Debt
Major credit card debts (Visa, AmEx, Mastercard, Discover) continued
Department store credit card debts
Other credit card debts (gas, phone cards, etc.)
Creditor Name and Address, Account Number, if any Date/range of dates when debt was incurred
Amount owed
Name and address of codebtor, if any What is debt for? Is debt secured by any property?
Do you dispute the debt?
OFFICE USE ONLY Lawsuit pending? Collection agency Sched. assigned? D,E or Counsel for F? creditor?
Type of Debt
Unpaid medical bills
Unpaid utility bills
Unpaid rent
Unpaid taxes
Creditor Name and Address, Account Number, if any Date/range of dates when debt was incurred
Amount owed
Name and address of codebtor, if any What is debt for? Is debt secured by any property?
Do you dispute the debt?
OFFICE USE ONLY Lawsuit pending? Collection agency Sched. assigned? D,E or Counsel for F? creditor?
Type of Debt
Unpaid alimony or child support
Unpaid service fees
All other unpaid debts/ bills
Creditor Name and Address, Account Number, if any Date/range of dates when debt was incurred
Amount owed
Name and address of codebtor, if any What is debt for? Is debt secured by any property?
Do you dispute the debt?
OFFICE USE ONLY Lawsuit pending? Collection agency Sched. assigned? D,E or Counsel for F? creditor?
Section 4 ~ Unexpired Leases and Contracts (Schedule G) List below any leases or contracts that are still current that you are a party to. Include residential, car and business leases, and service and business contracts. Nature and Description of Contract
Name and Address of Other Party or Parties
Date that Contract Expires
Section 5 ~ Current Income Marital Status: 9 Married 9 Single 9 Divorced 9 Separated 9 Widowed
List all dependents of you and your spouse, their ages, and relationship to you: ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________
Part A. Debtor’s Income 1. What is your occupation? ___________ 2. Name and address of your employer: ________________________________ ________________________________ ________________________________
Part B. Joint Debtor’s Income 1. What is you spouse’s occupation? ____________ 2. Name and address of you spouse’s employer: ________________________________________ ________________________________________ ________________________________________
3. How long have you been employed there? ________________________________ 4. What is the gross amount of your paycheck, before taxes, other deductions are taken out? $_________ 5. How often do you get paid? ______________ 6. Do you receive overtime pay outside of your salary? _____ If so, how much per month? __________________ 7. How much is taken out of each paycheck for taxes and social security ? $_______________ 8. How much is taken out for insurance? $_________ 9. How much for union dues? $_________ 10. Are there other deductions? If so, what are they and how much? ___________________________
3. How long employed there? __________________ 4. What is the gross amount of your spouse’s paycheck, before taxes/other deductions? $____________ 5. How often does your spouse get paid? __________ 6. Does you spouse receive overtime pay outside of your salary? ___________ If so, how much per month? ___________________ 7. How much is taken out of each paycheck for taxes and social security? $________________ 8. How much is taken out for insurance? $___________ 9. How much for union dues? $_______________ 10. Are there other deductions? If so, what are they and how much? ___________________________________
Do you receive.... a) income from business operations outside of your regular paycheck listed above? If so, what is the Business and how much do you receive per month? ____________________________________
Does your spouse receive ..... a) income from business operations outside of the regular paycheck listed above? If so, what is the business and how much does your spouse receive per month? ______________________________________________
b) income from real estate property? If so, how b) income from real estate property? If so, how much per much per month? __________________________ month? ________________________________________ c) interest or dividends? If so, how much per month? ________________________________________
c) interest or dividends? If so, how much per month? _______________________________________________
d) alimony or family support payments for your use for the care of your dependents? If so, how much per month? _______________________________
d) alimony or family support payments for spouse’s use or for care of dependents? If so, how much per month? _______________________________________________
e) social security or other forms of monetary government assistance? ____________________
e) social security or other forms of monetary government assistance? _____________________________________
f) retirement or pension money? _______________ Do you have any other sources of income not listed? ______________________
f) retirement or pension money? _____________________ Does your spouse have any other income not listed? _________________________
Are you or your spouse expecting any increase or decrease in salary of more than 10% in the next year? If so, explain.
______________________________________________________________________________________
Section 6 ~ Current Expenses Do you and your spouse maintain separate households? your household and another for your spouse’s.
G No G Yes
If so, fill one page out for
The following questions ask for your expenses each month. If you are unsure of the amount you pay each month, but know the amount for a different period (per week, per day, every 2 months, etc.), write in the amount and the frequency that you pay the amount. Indicate how much you pay for each item each month.... 1. Your rent or your home mortgage $_____________________________ Does that amount include real estate taxes? G No GYes Does that amount include property insurance? G No G Yes 2. Electricity $_____________________________ 3. Natural gas or propane $_____________________________ 4. Water and sewage $_____________________________ 5. Telephone service, including long distance $_____________________________ 6. Do you have any other utility bills? If so, what, and how much per month? ____________________________________________ $_____________________________ ____________________________________________ $_____________________________ 7. Home maintenance, including repairs and general upkeep $_____________________________ 8. Food $_____________________________ 9. Clothing $_____________________________ 10. Laundry and dry cleaning $_______________________ ______ 11. Transportation (not including car payments) $_____________________________ 12. Entertainment, recreation, newspapers, magazines $_____________________________ 13. Charitable contributions $_____________________________ 14. Insurance not deducted from paycheck a) Homeowner’s or renter’s insurance $_____________________________ b) Life insurance $_____________________________ c) Health insurance $_____________________________ d) Auto insurance $_____________________________ e) Other insurance __________________________ $_____________________________ 15. Taxes not deducted from paycheck $_____________________________ 16. Installment payments for car, furniture, etc. (Specify) ____________________________________________ $_____________________________ ____________________________________________ $_____________________________ 17. Alimony, maintenance, support paid to others $_____________________________ 18. Payments for support of dependents not living at home $_____________________________ 19. Expenses for operation of business $_____________________________ 20. Medical and dental expenses $_____________________________ 21. Other expenses not otherwise listed ____________________________________________ $_____________________________ ____________________________________________ $_____________________________ ____________________________________________ $_____________________________
Section 7 ~ Statement of Financial Affairs If you are filing jointly with your spouse, include information about you and your spouse. If you are filing under chapter 12 or 13, and you are married and not separated, you must provide information about your spouse even if you are not filing jointly. If you have no information to report for a question, check the “NONE” box. 1. Income from employment or operation of business State your gross income from employment or operation of a business: If you have not received an income from employment during the two years immediately preceding this calendar year, check this box: G NONE Period
$Amount
Source
Husband/Wife
January 1 of this year through date of commencement of case
Last year, (January 1- December 31)
The year before last, (January 1- December 31)
2. Income other than from employment or operation of business State the amount of income received other than from employment or operation of business during the two years immediately preceding the commencement of this case: GNONE Period
$Amount
Source
Husband/Wife
During the last year
Year before last
3. Payments to creditors a.) List all payments on loans, installment purchases of goods or services, and other debts, aggregating more than $600 to any creditor made within 90 days immediately preceding the commencement of this case. GNONE Name and Address of Creditor
Dates of Payments
Amount Paid
Amount still owed
b.) List all payments made within one year immediately preceding the commencement of this case ro creditors who were (“Insiders” include you relatives, your business partners and their relatives, your corporations, or your affiliates.) GNONE Name and Address of Creditor and Relationship to you Dates of Payments Amount Paid Amount Still Owed
4. Suits, executions, garnishments and attachments a.) List all suits and administrative proceedings to which you are or were a party within one year preceding the filing of this case. GNONE Case of Suit and Case Number
Nature of Preceding
Court or Agency and Location
Status or Disposition
b.) Describe all property that has been garnished, seized, or attached under any legal or equitable process within one year immediately preceding the commencement of this case. GNONE Name and Address of Person/Company for Whom the Property Was Seized/(Creditor)
Date of Seizure
Description and Value of Property
5. Repossessions, foreclosures, and returns List all property that a 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. GNONE Name and Address of Creditor
6. Assignments and receiverships
Date of Repossession, Foreclosure, Transfer or Return
Description and Value of Property
a.) Describe any assignment of property for the benefits of creditors made within 120 days immediately preceding the commencement of this case. GNONE Name and Address of Assignee
Date of Assignment
Terms of Assignment/Settlement
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. GNONE Name and Address of Custodian
Name and location of Court , Case Title and Number
Date of Order
Description and Value of Property
7. Gifts 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 aggregating less than $100 per recipient. GNONE Name and Address of Recipient
Relationship to You, if any
Date of gift
Description and Value of Gift
8. Losses List all losses from fire, theft, gambling or other casualty within one year immediately preceding the commencement of this case or since the commencement of this case. GNONE Description and Value of Property
Description of Circumstances and Amount Covered by Insurance, if any
Date of Loss
9. Payments related to debt counseling or bankruptcy List all payments made or property transferred by or on behalf of the debtor to any persons, including attorneys
for consultation concerning debt consultation, relief under the bankruptcy law or preparation of the petition in bankruptcy within one year preceding the commencement of the case. GNONE Name and Address of Payee
Date of Payment
Name of Person Who paid, if not You
Amount of Money/Description and Value of Property
10. Other transfers, (including sale of your property) List all other property, other than the property transferred in your ordinary course or financial affairs, transferred either absolutely or as a security within one year immediately preceding the commencement of this case. GNONE Name and Address of Transferee and Relationship to you
Date of Transfer
Description of Property Transferred and Value Received
11. Closed financial accounts List all financial accounts and instruments held in your name or for your benefit which were closed, sold, or otherwise transferred within one year immediately preceding the commencement of this case. GNONE Name and Address of Institution
Type and Number of Accounts & Final Balance
Amount and Date of Sale or Closing
12. Safe deposit boxes List each safe deposit or other box or depository in which you have or have had securities, cash, or other valuables within one year immediately preceding the commencement of this case. GNONE Name and Address of Bank or other Depository
13. Setoffs
Name and Address of Those With Access to Box or Depository
Description Of Contents
Date of Transfer, if any
List all setoffs made by any creditor, including a bank, against a debt or deposit of yours within 90 days preceding the commencement of this case. GNONE Name and Address of Creditor
Date of Setoff
Amount of Setoff
14. Property held for another person List all property that you hold or control this is owed by another person. GNONE Name and Address of Owner
Description and Value of Property
Location of Property
15. Prior address of debtor If you have moved within the two years immediately preceding the commencement of this case, list all residences during the last two years, excluding your present address. GNONE Address
Your name at the Time
Date of Occupancy
The following questions, #16-21 are only to be answered if you are a corporation or partnership or if you have been, in the two years immediately preceding this case, an officer, director, managing executive, or owner of more than 5% of the voting securities of the corporation; a partner, other than a limited partner, of a partnership, a sole proprietor, or otherwise self-employed. 16. Nature, location and name of business in which you were an officer, director, managing executive, or owner of more than 5% or more of voting or equity securities within the two years immediately preceding the commencement of this case. GNONE Name and Address
Nature of Business
17. Books, records, and financial statements
Dates of Operation-Beginning and End
a.) List all bookkeepers and accountants who, within the six years immediately preceding the filing of this bankruptcy case, kept or supervised the keeping of books of accounts and records. GNONE Name and Address
Dates Services Rendered
b.) List all firms or individuals who, within the two years immediately preceding the filing of this bankruptcy, have audited the books of account and records, or preparing a financial statement of the debtor. GNONE Name and Address
Dates Services Rendered
c.) List all firms or individuals who, all the time of the commencement of this case, were in possession of your books of account and records. If the records are not available, explain. GNONE Name and Address
Comments
d.) List all financial institutions, creditors and other parties, including mercantile and trade agencies, to whom a financial statement was issued by the debtor within two years immediately preceding the commencement of this case. GNONE Name and Address
Date Issued
18. Inventories a.) List the dates of the last two inventories taken of your property, the name of the person who supervised the taking of each inventory, and the dollar amount and basis of each inventory. GNONE Date of Inventory
Inventory Supervisor
Dollar Amount of Inventory (Specify cost, market, or other basis)
b.) List the name and address of the person possessing the records of each of the two inventories reported. GNONE
Date of Inventory
Name and Address of Custodian of Inventory Records
19. Current partners, officers, directors, and shareholders a.) If your business is a partnership, list the nature and percentage of partnership interest of each member of the partnership. GNONE Name and Address
Nature and Percentage of Interest
b.) If your business is a corporation, list all officers and directors of the corporation, and each stockholder who directly owns, controls, or holds 5% or more of the voting securities of the corporation. GNONE Nature and Percentage Name and Address
Title
of Stock Ownership
20. Former partners, officers, directors, and shareholders a.) If your business is a partnership, list each member who withdrew from the partnership within one year immediately preceding the commencement of this case. GNONE Name and Address
Date of Withdrawal
b.) If your business is a corporation, list all officers or directors whose relationship with the corporation terminated within one year immediately preceding the commencement of this case. GNONE Name and Address
Title
Date of Termination
21. Withdrawals from a partnership or distributions by a corporation If your business is a partnership or corporation, list all withdrawals or distributions credited or given to an insider, including compensation in any form, bonuses, loans, stock redemptions, options exercised and any other perquisite during one year preceding the commencement of this case. GNONE Name and Address of Property
Date and Purpose Recipient and Relationship to You
Amount of Money or Description of Withdrawal and Value of
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