Bankruptcy questionnaire

The answers you provide below will be used by this office to determine your eligibility for Bankruptcy
relief and, if you choose to file, it will be used to complete your Bankruptcy Petition. PLEASE ANSWER
QUESTIONS COMPLETELY AND ACCURATELY.
I attest under penalty of perjury that the answers I will provide are true, correct, and accurate to the best
of my knowledge and I have not knowingly or intentionally omitted any information:

________________________

__________________________

Signature
Date
Signature
Date
______________________________________________________________________________
1. REAL PROPERTY: Do you own your home? Yes_____ No_____
What is it worth? _________________ Purchase Date_____________________
Total owed on FIRST mortgage?___________ Payment____________________
i. Mortgage Company Name, Phone Number, AND Account
Number____________________________________________________
Total owed on SECOND mortgage? ___________ Payment__________________
i. Mortgage Company Name, Phone Number, AND Account
Number____________________________________________________
Are Taxes and Insurance Included? Yes_____ No_____
Do you want to keep this property? Yes____No____# of Months behind? _____
Do you receive rent from tenants living in this property? Yes_____ No_____
i. List Tenant Names ___________________________________________
ii. List amount $___________________ per month
iii. List beginning and end dates of lease ____________________________
Do you own any other LAND OR RENTAL PROPERTY? Yes_____ No_____
i. Property Address ___________________________________________
ii. Mortgage Company Name, Phone Number, AND Account
Number____________________________________________________
iii. Debt Amount________ Payment ________
iv. Do you want to keep this property? Yes_____ No_____
2. BANK ACCOUNT INFORMATION
Name of Bank________________
i. Balance_______________ (circle account type) Checking or Savings
Name of Bank________________
i. Balance_______________ (circle account type) Checking or Savings
3. LANDLORD INFORMATION. Complete this section if you pay rent for an apartment or house.
Name of and Address of
Landlord____________________________________________
Security Deposit $______________

Did you sign a lease? Yes_____ No_____ Are payments Current? Yes_____ No_____

4. HOUSEHOLD GOODS: Provide a yard-sale value for each item listed below.
All bedroom
Stereo
Clothing
furniture
DVD
Furs
Living room
Washer and
Lawnmower
Kitchen table
Dryer
Tools
Stove
Computer
Refrigerator
Ipod
Microwave
Digital
Camera
TVs
Jewelry
i. Detailed Description_________________________________________________
Collections (i.e, Comic books, coins, art, stamps?)
i. Detailed Description________________________________________________
Guns, hobby, or sporting equipment?
i. Detailed Description________________________________________________
Pets
ii. Detailed Description_______________________________________________
Do you have a lawsuit or potential lawsuit against any person or business?
i. If yes, please describe______________________________________________
5. Insurance Policies with a Cash Value? _______________________________________________
6. 401(k) with? ___________________ $___________________
7. Stocks or bonds? ________________________________________________________________
8. VEHICLEScomplete the section below for ALL owned vehicles.

If vehicle is owned free and clear enter N/A under Name

of Lender.

Name of Lender_______________________Account Number______________________

Type of Car? _______________________ Number of Miles? _______________________
When did you buy the car? _______________ How much do you owe? $_____________
Monthly Payment? $________________ Are payments current? Yes______ No______
How many months behind? ____________ Do you want to keep it? Yes_____ No______

Name of Lender_______________________Account Number______________________

Type of Car? _______________________ Number of Miles? _______________________
When did you buy the car? _______________ How much do you owe? $_____________
Monthly Payment? $________________ Are payments current? Yes______ No______
How many months behind? ____________ Do you want to keep it? Yes_____ No______

Name of Lender_______________________Account Number______________________

Type of Car? _______________________ Number of Miles? _______________________
When did you buy the car? _______________ How much to you owe? $_____________
Monthly Payment? $________________ Are payments current? Yes______ No______
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How many months behind? ____________ Do you want to keep it? Yes_____ No______
Any other motorized thingsboats, motorcycles, jet skis, etc?
List items and value_________________________________________________
Do owe any child support, alimony, or taxes? Yes_____ No______
Child Support/Alimony (circle one)
i. Amount? $_______ Are you Current? Yes_____ No______
ii. Name and Address of recipient ________________________________________
Taxes
i. Amount? _______ Type?____________________ (i,e,. Income tax, property tax)
Is anyone co-signed on your debt?
Which Debt(s)? _________________________________________________________
Name and Address of Co-signer____________________________________________
Do you have a current contract with your Cell Phone Company or any other Service company?
(i.e., Sprint, Verizon, AT & T, T-Mobile, ADT, Dish Network, etc.). If so, list all that apply and list
whether you desire to keep the contract or reject:

____________________________________________________________________________________
____________________________________________________________________________________
13. LIVING EXPENSES Provide a monthly payment for each:
Rent?
Laundry?
Electricity bills?
Out of pocket medical?
Water bill?
Gas?
Cable?
Entertainment?
Internet?
Charitable contributions?
Phone?
Renters insurance?
Cell?
Life insurance?
Food?
Car insurance?
Home repair and maintenance?
Personal grooming?
Clothing?
Any other?
14. Have you gotten income from any other source BESIDES employment in the past following
years? (i.e., Social Security, Food Stamps, unemployment, lottery winnings, etc.?)
2011
2010
2009
Please list how many months you received the above benefits and the amount of the
benefits listed _________________________________________________________
15. Have you paid ANY creditors more than $600.00 in the past 90 days?
List Creditor, payment date and amount paid_________________________________
List Creditor, payment date and amount paid_________________________________
16. Have you been sued or garnished in the past year.

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List County of Judgment and Creditor name___________________________________

If garnished, list Creditor and total amount garnished____________________________
How long has garnishment been in effect?_____________________________________
Any REPOS or FORECLOSURES in past 2 years?
If yes, list item taken and action date__________________________________________
Have you paid anyone for debt consolidation in past year?
Name debt consolidator and amounts paid_____________________________________
Sold any CARS or LAND in past 2 years or given away anything VALUABLE? Yes____ No_____
List sales price and how income was spent_________________________________
Closed any checking accounts in past year? Yes_____ No _____
List name of bank, date account was closed, and close date
balance_______________________________________________
Do you have a safe deposit box? Yes_______ NO_______
List contents of box______________________________________________
Are you BORROWING any property from anyone? Such as a Car, furniture, tools, etc?
List item and name and address of owner_____________________________________
Have you lived at your current address the past 3 years? Yes_____ No______
List addresses of the past 3 years and the dates in which you resided at each address:
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________

24. Do you have a pending lawsuit or potential lawsuit against any person or business?
No_____ If Yes, list details and status of lawsuit:
________________________________________________________________________
________________________________________________________________________
25. YOUR JOB:
Where are you employed?__________________________________________________
Address of employer_______________________________________________________
How often are you paid?____________________________________________________
How long have you been employed with this company?___________________________
26. SELF-EMPLOYED:
Are you Self-Employed? Yes_____ No_____
Ownership interest in business in the last 6 years? Yes_____ No_____
Name of Business___________________Type of Business ____________________
Business Open Date__________ Close Date___________ EIN Number____________
Partner name and address_________________________________________________