Name - Debtor			Phone (Home)
Spouse			Phone (Work)
			Phone (Mobile)
Address			Years at this address
Marital Status -	Married	___
	Single	___
	Separated	___
	Divorced	___
	Widowed	___

 

Dependants (other than present spouse)
Name	Relationship	Date of Birth	Residence

 

	Debtor	Spouse
Other names used in the past 6 years
Social Security Number
Occupation
Name & Address of current employer
Length of time employed

 

Please answer the following questions as completely as possible.
Do you have all of your financial books and records from the last two year?
____ Yes		____ No			____ Some missing
If any of your records are missing, please explain.
Are you holding any property that belongs to you? _____ If yes, Explain
Is anyone else holding any property that belongs to you? _____ If yes, Explain
Have you had any fire, theft or gambling losses in the last year? _____ If yes, Explain
Are you currently responsible for any leases or contracts (cell phone, apt, etc...)? _____ If yes, Explain
Have you transferred any of your property to someone else during the last year? _____ If yes, Explain
Has any of your property been repossessed in the past year? _____ If yes, Explain
Have any of your wages been garnished or attached? _____ If yes, Explain
Have you paid off any loans in the past year (including loans from family, friends, banks, etc...)
Have any of your wages or property been assigned to anyone else?_____ If yes, Explain
Have you ever been involved in any other bankruptcy proceedings?_____ If yes, Please provide dates
Is any of your property in the hands of a receiver or trustee?
Have you been a party to any lawsuits in the past year?_____ If yes, please state the title of the lawsuit, the court in which it was filed, the type of suit (i.e. personal injury, collection, etc...) and the outcome or current status.
Have you made payments to any attorneys for any services rendered during the past year?_____ If yes, state the name and address of the attorney, the amount paid, and what services were provided.
Do you owe money to anyone who may have previously been employed by you?_____
Do you owe money to any farmers?_____
Do you owe money to any fisherman?_____
Are you holding money for anyone which was given to you as a deposit for rental of property, purchase of goods or provision of services?
Are you entitled to any other refunds/inheritances that you have not yet received?
Money owed to you - list names, addresses and reason why money is owed to you. Include security deposits being held.
Name & Address		Is there any written documentation that proves the debt is owed?			Amount owed
Have you repaid any loans during the past year? (Other than regular monthly payments to creditors)
Name & Address of Lender	Original loan amount		Date received	Was Lender a relative?		Date of repayment
Do you owe taxes to: The United States?_____ Any State?_____ Any other taxing authority?__________
Amount of tax refunds received from your return last year?
If you have any questions or concerns about the bankruptcy proceeding, what will occur, and how it will affect your property and finances, pleas make a note of it here so that we can discuss it at our next meeting.

 

PROPERTY The following section is for listing all property which you own. It is absolutely necessary to include all property, regardless of its value or where it may be located.
	Description and Location (Attach a separate sheet if needed)	Owned by Husband, Wife or Jointly	Present Market Value (State how you arrived at the value)	Amount of Lien(s), If Any
Cash on Hand
Household goods, supplies and furnishings, including audio, video and computer equipment (Detailed required)
Personal items: clothing and jewelry (watches, wedding bands, etc...)
Real Property: land /houses
Automobiles, motorcycles, boat, trailers, etc...
Bank Accounts, including checking, savings, money market, cds, and safe deposit boxes
Stocks, Bonds, 401K's
Art objects, valuable collections (stamps, coins antiques, etc...)
Sports, photographic or hobby equipment, including firearms
Animals

 

	Debtor	Spouse
Names and addresses of all other employers in the past year.
Is employment subject to seasonal of other change?
Current Income (use pay-stub)
Circle One - I/We are paid     Weekly | Bi-Weekly | Monthly
Gross Wages
Tax deduction
Insurance Deduction
Union Dues
401k Loans
401k Contribution
Other Deductions (specify)
Net Income (Take home pay)
All other sources of income:
Interest & dividends
Social Security
Child Support
Real Estate Income
Pension/Retirement
Other (specify)
Have you engaged in any business within the past five (5) years as a corporate officer, partner, or sole proprietor? If Yes, list all the details including names, dates, addresses and status of business now.
Income from trade or profession; use W-2 forms or tax returns.
200__
200__
Current YTD
Income from any other source. Specify source (Public assistance, workers comp, alimony, etc...)
200__
200__
Current YTD

 

CURRENT MONTHLY EXPENSES
(Figure at 4.3 weeks per month)
Rent or mortgage payment
Utilities:
Heat/Electric
Water
Telephone
Garbage
Cable TV
Mobile Phone
Internet Access
General Home Maintenance
Food
Clothing
Laundry and Dry Cleaning
Insurance Payments:
Automobile
Life
Homeowners/Renters
Medical (if not deducted from you pay)
Other
Transportation (gas and repairs only)
Automobile Installment Payments
Medical & Drug Expenses
Union Dues (if not deducted from you pay)
Taxes (note deducted from wages or included in mortgage payment)
Alimony, Maintenance & support
Charitable Contributions
Recreation (include gifts, vacations, books, and magazines)
Other expenses not listed above (specify):
__________________________
__________________________
__________________________

 

DEBTS

List any and all individuals, business, and creditors to which you owe money. Include everyone no matter how old the debt or to whom the debt is owed. If you list a car loan as a debt, please indicate whether the car has been repossessed or you still have the car. Include all mortgages, car loans, student loans, taxes, debts to friends and family members, etc...

EVERY DEBT MUST BE LISTED

Creditor's Name/Address and Account Number	Who is responsible for the debt? Husband/Wife or Both	Type of debt (Secured or Unsecured)	Amount Owed	Date you incurred this debt or range of dates debt was incurred

 

Please bring the following documents with you when you return with this completed questionnaire along with your full retainer.

1. All correspondence received from collection agencies or attorneys.

2. All deed to any land or houses.

3. Titles for all motor vehicles.

4. Court papers including summonses, complaints, and judgments.

5. Tax returns and W-2s from the last two years

6. Any documents establishing claims to money owed to you.

7. Documents evidencing security (loan arrangements, papers signed when making a major purchase, lien agreements, or anything else showing that your property may be held as collateral for a loan).

8. Any other letters and papers you have received from creditors.

9. Pay stubs from the past two pay periods.

10. Proof of balances due on any mortgages.

11. Proof of value for any land or houses.

12. Most recent property tax bill.

 

Statement by Debtor(s)

          I have prepared and reviewed all of the information contained in the foregoing questionnaire and herby verify that it is true and correct to the best of my knowledge. I understand that the information which I have provided herein will be used for the preparation of a bankruptcy petition under Chapter ___ of the Bankruptcy Law. My rights and obligations under the Bankruptcy Law have been fully explained to me and I have read the attached "Bankruptcy Information Sheet". I understand that my failure to include any creditor in this document may result in my being required to pay that creditor in full even after my other debts have been discharged.

          I further understand that the attorneys fee paid in this matter does not include representation in any dischargeabilty actions, relief from stay actions or any other adversary proceeding.

          If any amendments to filed schedules are required as a result of my failure to provide my attorney with any requested information,  I agree to pay an additional attorney fee of $100.00 per amendments, plus any required filing fees.

          If I fail to appear at my initial Section 341 meeting and/or attendance is required at any 341 meeting due to my failure to provide requested documents or information, I agree to pay an additional attorney's fee of $150.00 per additional appearance.

          I understand that certain debts are generally non-dischargeable, including child support, student loans and most tax obligations.

Dated:_______________________

 

____________________________

Debtor

 

____________________________

Debtor

 

BANKRUPTCY INFORMATION SHEET

Bankruptcy law is a federal law. This sheet gives you some general information about what happens in a bankruptcy case. The information here is not complete. you may still need legal advice.

WHEN YOU FILE BANKRUPTCY:

You can choose the kind of bankruptcy that best meets your needs:

• Chapter 7 - A trustee is appointed to take over your property. Any property of value will be sold or turned into money to pay your creditors. You may be able to keep some personal items and possibly real estate depending on the law of the state where you live.

• Chapter 13 - You can usually keep your property, but you must earn wages or have some other source of regular income and you must agree to pay part of your income to your creditors. The Court must approve your repayment plan and your budget. A trustee is appointed and will collect the payments from you, pay your creditors, and make sure you live up to the terms of your repayment plan.

• Chapter 11 - This is used mostly by businesses. In chapter 11, you may continue to operate your business, but your creditors and the Court must approve a plan to repay your debts. There is no trustee unless the Judge decides that one is necessary; if a trustee is appointed, the trustee takes control of your business and property.

If you have already filed bankruptcy under chapter 7, you may be able to change your case to another chapter.

Your bankruptcy may be reported on your credit record for as long as ten years. It can affect your ability to receive credit in the future.

WHAT IS A BANKRUPTCY DISCHARGE AND HOW DOES IT OPERATE?

One of the reasons people file bankruptcy is to get a “discharge”. A discharge is a Court order which states that you do not have to pay most of your debts. Some debts cannot be discharged. For example, you cannot discharge debts for:

• Most taxes

• Child support

• Alimony

• Most student loans

• Court fines and criminal restitution

• Personal injury caused by driving drunk or under the influence of drugs

The discharge only applies to debts that arose before the date you filed. Also, if the Judge finds that you received money or property by fraud, that debt may not be discharged.

It is important to list all your property and debts in your bankruptcy schedules. I you do not list a debt, for example, it is possible the debt will not be discharged.

The Judge can also deny your discharge if you do something dishonest in connection with your bankruptcy case, such as destroy or hide property, falsify records, or lie, or if you disobey a Court order.

You can only receive a chapter 7 discharge once every six years. No one can make you pay a debt that has been discharged, but you can voluntarily pay any debt you wish to pay. You do not have to sign a reaffirmation agreement or any other kind of document to do this.

Some creditors hold a secured claim (for example, the bank that holds the mortgage on your house or the loan company that has a lien on your car). You do not have to pay a secured claim if the debt is discharged, but the creditor can still take the property.

WHAT IS A REAFFIRMATION AGREEMENT?

Even if a debt can be discharged, you may have special reasons why you want to promise to pay it. For example, you may want to work out a plan with the bank to keep your car. To promise to pay that debt, you must sign and file a reaffirmation agreement with the Court. Reaffirmation agreements are under special rules and are voluntary. They are not required by bankruptcy law or by any other law. Reaffirmation agreements:

• Must be voluntary;

• Must not place too heavy a burden on you or your family;

• Must he in your best interest; and

• Can be canceled anytime before the Court issues your discharge or within 60 days after the agreement is filed with the Court, whichever gives you the most time.

If you are an individual and you are not represented by an attorney, the Court must hold a hearing to decide whether to approve the reaffirmation agreement. The agreement will not be legally binding until the Court approves it.

If you reaffirm a debt end then fail to pay it, you owe the debt the same as though there was no bankruptcy. The debt will not be discharged and the creditor can take action to recover any property on which it has a lien or mortgage. The creditor can also take legal action to recover a judgment against you.

If you want more information or have questions about how the bankruptcy laws affect you, you may need legal advice. The trustee in your case is not responsible for giving you legal advice.