Bankruptcy Questionnaire

Bankruptcy Questionnaire.

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Bankruptcy Questionnaire

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Step 1 of 24 - Your Information

1. Your Information 2. Spouse Information 3. Dependents 4. Mobile Home 5. Real Property 6. Vehicles 7. Other Vehicles 8. Personal Property 9. Financial Assets 10. Investment Assets 11. Other Assets 12. Business Assets 13. Secured Creditors 14. Unsecured Creditors 1-10 15. Unsecured Creditors 11-20 16. Unsecured Creditors 21-30 17. Unsecured Creditors 31-40 18. Unsecured Creditors 41-50 19. Your Income 20. Spouse Income 21. Past Income 22. Household Expenses 23. Financial Affairs

What is your name?*

Enter your full name including your middle initial. If you are a Sr., Jr., III, etc. be sure to include it.

First Middle Last Suffix

Have you been known by any other names in the last 8 years?*

All other names used by you in the last 8 years. Include married, maiden, and trade names.

Yes

Other Name #1*

First Middle Last Suffix

Other Name #2

First Middle Last Suffix

Other Name #3

First Middle Last Suffix

What is your Social Security Number?*

What is your date of birth?*

MM slash DD slash YYYY

What is the best phone number we can reach you at?*

What is your physical address?*

List your current physical residence address. If you have a separate mailing address, you can list it below.

Street Address Address Line 2 City State ZIP Code

In what county do you currently reside?*

Have you lived at this address for at least the last 3 years?*

List all the places you have lived in the last 3 years. Do not include where you live now.

Yes

Prior Address #1*

Street Address Address Line 2 City State ZIP Code

Prior Address #1 move in date?*

Enter at least the month and year you moved in. The exact date is not important, but try to be as accurate as possible.

MM slash DD slash YYYY

Prior Address #1 move out date?*

Enter at least the month and year you moved out. The exact date is not important, but try to be as accurate as possible.

MM slash DD slash YYYY

Have you lived anywhere else in the last 3 years?*

Yes

Prior Address #2*

Street Address Address Line 2 City State ZIP Code

Prior Address #2 move in date?*

MM slash DD slash YYYY

Prior Address #2 move out date?*

MM slash DD slash YYYY

Have you lived anywhere else in the last 3 years?*

Yes

Prior Address #3*

Street Address Address Line 2 City State ZIP Code

Prior Address #3 move in date?*

MM slash DD slash YYYY

Prior Address #3 move out date?*

MM slash DD slash YYYY

Do you have a different mailing address?*

Yes

What is your mailing address?*

Make sure you list any mailing address that is different than your physical address. This will be the address to which all correspondence will be sent.

Street Address Address Line 2 City State ZIP Code

Have you ever filed bankruptcy before?*

If you have filed more than once before, list the last time you filed.

Yes

When did you file your last bankruptcy?*

MM slash DD slash YYYY

What Chapter?*

Did you receive a discharge?*

1. Your Information 2. Spouse Information 3. Dependents 4. Mobile Home 5. Real Property 6. Vehicles 7. Other Vehicles 8. Personal Property 9. Financial Assets 10. Investment Assets 11. Other Assets 12. Business Assets 13. Secured Creditors 14. Unsecured Creditors 1-10 15. Unsecured Creditors 11-20 16. Unsecured Creditors 21-30 17. Unsecured Creditors 31-40 18. Unsecured Creditors 41-50 19. Your Income 20. Spouse Income 21. Past Income 22. Household Expenses 23. Financial Affairs

Are you married?*

This includes legal messages, as well as common-law marriages.

Yes

Is your spouse filing with you?*

Yes

What is your spouse's name?*

Enter your spouse's full name including middle initial. If your spouse is a Sr., Jr., III, etc. be sure to include it.

First Middle Last Suffix

Has your spouse been known by any other names in the last 8 years?*

All other names used by your spouse in the last 8 years. Include married, maiden, and trade names.

Yes

Spouse's Other Name #1*

First Middle Last Suffix

Spouse's Other Name #2

First Middle Last Suffix

Spouse's Other Name #3

First Middle Last Suffix

What is your spouse's social security number?*

What is your spouse's date of birth?*

MM slash DD slash YYYY

What is your spouse's phone number?*

Do you and your spouse live in the same household?*

Yes

What is your spouse's physical address?*

If you and your spouse maintain separate households, list your spouse's current physical residence address. If your spouse has a separate mailing address,list it below.

Street Address Address Line 2 City State ZIP Code

In what county does your spouse currently reside?*

Does your spouse have a different mailing address?*

Yes

What is your spouse's mailing address?*

Street Address Address Line 2 City State ZIP Code

Has your spouse ever filed bankruptcy before?*

If your spouse has filed more than once before, list the last time filed.

Yes

When did your spouse last file bankruptcy?*

MM slash DD slash YYYY

What Chapter did your spouse file?*

Did your spouse receive a discharge?*

1. Your Information 2. Spouse Information 3. Dependents 4. Mobile Home 5. Real Property 6. Vehicles 7. Other Vehicles 8. Personal Property 9. Financial Assets 10. Investment Assets 11. Other Assets 12. Business Assets 13. Secured Creditors 14. Unsecured Creditors 1-10 15. Unsecured Creditors 11-20 16. Unsecured Creditors 21-30 17. Unsecured Creditors 31-40 18. Unsecured Creditors 41-50 19. Your Income 20. Spouse Income 21. Past Income 22. Household Expenses 23. Financial Affairs

Do you have any dependents who live with you at least 50% of the time?*

Yes

How many dependents live in your household at lease 50% of the time?*

Dependent's name?*

First

Dependent's relationship to you?*

Dependent's age?*

Second dependent's name?*

First

Second dependent's relationship to you?*

Second dependent's age?*

Third dependent's name?*

First

Third dependent's relationship to you?*

Third dependent's age?*

Fourth dependent's name?*

First

Fourth dependent's relationship to you?*

Fourth dependent's age?*

Fifth dependent's name?*

First

Fifth dependent's relationship to you?*

Fifth dependent's age?*

1. Your Information 2. Spouse Information 3. Dependents 4. Mobile Home 5. Real Property 6. Vehicles 7. Other Vehicles 8. Personal Property 9. Financial Assets 10. Investment Assets 11. Other Assets 12. Business Assets 13. Secured Creditors 14. Unsecured Creditors 1-10 15. Unsecured Creditors 11-20 16. Unsecured Creditors 21-30 17. Unsecured Creditors 31-40 18. Unsecured Creditors 41-50 19. Your Income 20. Spouse Income 21. Past Income 22. Household Expenses 23. Financial Affairs

Do you own a mobile home?*

Yes

Who owns the mobile home?*

You

Your Spouse

You and Your Spouse Jointly

Other

What is the value of the mobile home?*

Report the current value. Current value is sometimes called fair market value and, for this form, is the fair market value as of the date of the filing of the petition. Current value is how much the property is worth, which may be more or less than when you purchased the property.

Is there a lien on the mobile home?*

Yes

Who is the lienholder on the mobile home?*

What is the lienholder's address?*

Street Address Address Line 2 City State ZIP Code

Account number on the mobile home debt?*

Balance on the mobile home debt?*

Monthly payment?*

What do you want to do with the mobile home?*

Keep it and keep making payments?

Surrender it and discharge the debt?

1. Your Information 2. Spouse Information 3. Dependents 4. Mobile Home 5. Real Property 6. Vehicles 7. Other Vehicles 8. Personal Property 9. Financial Assets 10. Investment Assets 11. Other Assets 12. Business Assets 13. Secured Creditors 14. Unsecured Creditors 1-10 15. Unsecured Creditors 11-20 16. Unsecured Creditors 21-30 17. Unsecured Creditors 31-40 18. Unsecured Creditors 41-50 19. Your Income 20. Spouse Income 21. Past Income 22. Household Expenses 23. Financial Affairs

Do you own any real estate?*

Real estate includes all real property like your residence, buildings, or land.

Yes

Is the address the same as your current residence address?*

Yes

What is the address of this property?*

Street Address Address Line 2 City State ZIP Code

What is the legal desccription of this property?

Upload a copy of the deed here.

Max. file size: 20 MB.

Who owns this property?*

You

Your Spouse

You and Your Spouse Jointly

Other

Is there a mortgage on this property?*

Yes

What is the name of the mortgage company?*

What is the mortgage company's address?*

Street Address Address Line 2 City State ZIP Code

What is the account number for the mortgage?*

How much is owed on the mortgage?*

Mortgage monthly payment?*

Is there a second mortgage on this property?*

Yes

What is the name of the second mortgage company?*

What is the second mortgage company's address?*

Street Address Address Line 2 City State ZIP Code

What is the account number for the second mortgage?*

How much is owed on the second mortgage?*

Second mortgage monthly payment?*

Do you own a second property?*

Yes

What is the address of the second property?*

Street Address Address Line 2 City State ZIP Code

What is the legal description of the second property?

You can upload a copy of the deed to your second property here.

Max. file size: 20 MB.

Who owns the second property?*

You

Your Spouse

You and Your Spouse Jointly

Other

Is there a mortgage on the second property?*

Yes

What is the name of the mortgage company for the second property?*

What is the mortgage company's address for the second property?*

Street Address Address Line 2 City State ZIP Code

What is the account number for the second property mortgage?*

How much is owed on the second property mortgage?*

Monthly mortgage payment on the second property?*

Do you own a third property?*

Yes

What is the address of the third property?*

Street Address Address Line 2 City State ZIP Code

What is the legal description of the third property?

You can upload a copy of the deed to your third property here?

Max. file size: 20 MB.

Who owns the third property?*

You

Your Spouse

You and Your Spouse Jointly

Other

Do you own a fourth property?*

Yes

What is the address of the fourth property?*

Street Address Address Line 2 City State ZIP Code

What is the legal description of the fourth property?

You can upload a copy of the deed to your third property here?

Max. file size: 20 MB.

Who owns the fourth property?*

You

Your Spouse

You and Your Spouse Jointly

Other

1. Your Information 2. Spouse Information 3. Dependents 4. Mobile Home 5. Real Property 6. Vehicles 7. Other Vehicles 8. Personal Property 9. Financial Assets 10. Investment Assets 11. Other Assets 12. Business Assets 13. Secured Creditors 14. Unsecured Creditors 1-10 15. Unsecured Creditors 11-20 16. Unsecured Creditors 21-30 17. Unsecured Creditors 31-40 18. Unsecured Creditors 41-50 19. Your Income 20. Spouse Income 21. Past Income 22. Household Expenses 23. Financial Affairs

Do you own any vehicles?*

Yes

How many vehicles do you own?*

What is the model year of the first vehicle?*

What is the make of the first vehicle?*

What is the model of the first vehicle?*

How many miles are on the first vehicle?*

What is the value of the first vehicle?*

Upload first vehicle title

Max. file size: 3 GB.

Who owns the first vehicle?*

You

Your Spouse

You and Your Spouse Jointly

Other

What is the model year of the second vehicle?*

What is the make of the second vehicle?*

What is the model of the second vehicle?*

How many miles are on the second vehicle?*

What is the value of the second vehicle?*

Upload second vehicle title

Max. file size: 3 GB.

Who owns the second vehicle?*

You

Your Spouse

You and Your Spouse Jointly

Other

What is the model year of the third vehicle?*

What is the make of the third vehicle?*

What is the model of the third vehicle?*

How many miles are on the third vehicle?*

What is the value of the third vehicle?*

Upload third vehicle title

Max. file size: 3 GB.

Who owns the third vehicle?*

You

Your Spouse

You and Your Spouse Jointly

Other

What is the model year of the fourth vehicle?*

What is the make of the fourth vehicle?*

What is the model of the fourth vehicle?*

How many miles are on the fourth vehicle?*

What is the value of the fourth vehicle?*

Upload fourth vehicle title

Max. file size: 3 GB.

Who owns the fourth vehicle?*

You

Your Spouse

You and Your Spouse Jointly

Other

What is the model year of the fifth vehicle?*

What is the make of the fifth vehicle?*

What is the model of the fifth vehicle?*

How many miles are on the fifth vehicle?*

What is the value of the fifth vehicle?*

Upload fifth vehicle title

Max. file size: 3 GB.

Who owns the fifth vehicle?*

You

Your Spouse

You and Your Spouse Jointly

Other

1. Your Information 2. Spouse Information 3. Dependents 4. Mobile Home 5. Real Property 6. Vehicles 7. Other Vehicles 8. Personal Property 9. Financial Assets 10. Investment Assets 11. Other Assets 12. Business Assets 13. Secured Creditors 14. Unsecured Creditors 1-10 15. Unsecured Creditors 11-20 16. Unsecured Creditors 21-30 17. Unsecured Creditors 31-40 18. Unsecured Creditors 41-50 19. Your Income 20. Spouse Income 21. Past Income 22. Household Expenses 23. Financial Affairs

Do you own any motorcycles?*

Yes

What is the model year of your motorcycle?*

What is the make of your motorcycle?*

What is the model of your motorcycle?*

What is the value of your motorcycle?*

Upload motorcycle title

Max. file size: 3 GB.

Who owns the motorcycle?*

You

Your Spouse

You and Your Spouse Jointly

Other

Do you own any other motorcycles?*

Yes

What is the model year of your second motorcycle?*

What is the make of your second motorcycle?*

What is the model of your second motorcycle?*

What is the value of your second motorcycle?*

Upload second motorcycle title

Max. file size: 3 GB.

Who owns the second motorcycle?*

You

Your Spouse

You and Your Spouse Jointly

Other

Do you own any watercraft?*

Yes

What is the model year of your watercraft?*

What is the make of your watercraft?*

What is the model of your watercraft?*

What is the value of your watercraft?*

Upload watercraft title

Max. file size: 3 GB.

Who owns the watercraft?*

You

Your Spouse

You and Your Spouse Jointly

Other

Do you own any recreational vehicles or trailers?*

Yes

What is the model year of your RV or trailer?*

What is the make of your RV or trailer?*

What is the model of your RV or trailer?*

What is the value of your RV or trailer?*

Upload RV or trailer title

Max. file size: 3 GB.

Who owns the RV or trailer?*

You

Your Spouse

You and Your Spouse Jointly

Other

1. Your Information 2. Spouse Information 3. Dependents 4. Mobile Home 5. Real Property 6. Vehicles 7. Other Vehicles 8. Personal Property 9. Financial Assets 10. Investment Assets 11. Other Assets 12. Business Assets 13. Secured Creditors 14. Unsecured Creditors 1-10 15. Unsecured Creditors 11-20 16. Unsecured Creditors 21-30 17. Unsecured Creditors 31-40 18. Unsecured Creditors 41-50 19. Your Income 20. Spouse Income 21. Past Income 22. Household Expenses 23. Financial Affairs

Do you own any household goods?*

Examples: Furniture, appliances, linens, dishware, utensils, garden tools, hand tools, etc.

Yes

What is the value of your household goods?*

List the collective garage sale value (not retail value) of all your household goods.

Do you own any electronics?*

Examples: Televisions and radios; audio, video, stereo, and digital equipment; computers, printers, scanners; music collections; electronic devices including cell phones, cameras, media players, games.

Yes

What is the value of your electronics?*

List the collective garage sale value (not retail value) of all your electronics.

Do you own any collections of value?*

Examples: Antiques and figurines; paintings, prints, or other artwork; books, pictures, or other art objects; stamp, coin, or baseball card collections; other collections, memorabilia, and collectibles.

Yes

Describe what collections you own.*

Do you own any sporting or hobby equipment?*

Examples: Sports, photographic, exercise, and other hobby equipment; bicycles, pool tables, golf clubs, skis; canoes and kayaks; carpentry tools; musical instruments.

Yes

Describe what sporting or hobby equipment you own.*

Do you own any firearms?*

Examples: Pistols, rifles, shotguns, ammunition, and related equipment

Yes

Describe what firearms you own.*

What is the value of your clothes?*

Examples: Everyday clothes, furs, leather coats, designer wear, shoes, accessories. List the garage sale value of all your clothes, rather than the retail value.

Do you own wedding, engagement, or anniversary rings?*

Examples: Wedding rings, engagement rings, and anniversary rings. Do not include other jewelry such as everyday jewelry, costume jewelry, heirloom jewelry, watches, gems, or gold.

Yes

What is the value of your wedding, engagement, and anniversary rings?*

List the collective pawn shop value of all your wedding rings, engagement rings, and anniversary rings.

Do you own any other miscellaneous jewelry?*

Examples: Everyday jewelry, costume jewelry, heirloom jewelry, watches, gems, gold, and silver.

Yes

What is the value of your other miscellaneous jewelry?*

List the collective pawn shop or garage sale value of all your miscellaneous jewelry.

Do you own any animals?*

Examples: Dogs, cats, birds, horses, cows, chickens, goats, and rabbits.

Yes

Describe what animals you own.*

1. Your Information 2. Spouse Information 3. Dependents 4. Mobile Home 5. Real Property 6. Vehicles 7. Other Vehicles 8. Personal Property 9. Financial Assets 10. Investment Assets 11. Other Assets 12. Business Assets 13. Secured Creditors 14. Unsecured Creditors 1-10 15. Unsecured Creditors 11-20 16. Unsecured Creditors 21-30 17. Unsecured Creditors 31-40 18. Unsecured Creditors 41-50 19. Your Income 20. Spouse Income 21. Past Income 22. Household Expenses 23. Financial Affairs

Do you have any cash on hand?*

Examples: Money you have in your wallet, in your home, in a safe deposit box, and on hand when you file your petition.

Yes

How much cash do you have on hand?*

Do you have any financial accounts?*

Examples: Checking, savings, or other financial accounts; certificates of deposit; shares in credit unions, brokerage houses, CashApp, Venmo, PayPal, and other similar institutions. If you have multiple accounts with the same institution, list each.

Yes

How many accounts do you have?*

What is the name of the first financial institution?*

What is the type of the first account?*

How much money is in the first account now?*

What is the name of the second financial institution?*

What is the type of the second account?*

How much money is in the second account now?*

What is the name of the third financial institution?*

What is the type of the third account?*

How much money is in the third account now?*

What is the name of the fourth financial institution?*

What is the type of the fourth account?*

How much money is in the fourth account now?*

What is the name of the fifth financial institution?*

What is the type of the fifth account?*

How much money is in the fifth account now?*

What is the name of the sixth financial institution?*

What is the type of the sixth account?*

How much money is in the sixth account now?*

1. Your Information 2. Spouse Information 3. Dependents 4. Mobile Home 5. Real Property 6. Vehicles 7. Other Vehicles 8. Personal Property 9. Financial Assets 10. Investment Assets 11. Other Assets 12. Business Assets 13. Secured Creditors 14. Unsecured Creditors 1-10 15. Unsecured Creditors 11-20 16. Unsecured Creditors 21-30 17. Unsecured Creditors 31-40 18. Unsecured Creditors 41-50 19. Your Income 20. Spouse Income 21. Past Income 22. Household Expenses 23. Financial Affairs

Do you have any stocks, bonds or mutual funds?*

Examples: Bond funds, investment accounts with brokerage firms, and money market accounts.

Yes

Describe what stocks, bonds or mutual funds you have.*

Do you own any business interests in any non-publicly traded stock, LLC, Partnership or joint venture?*

Yes

Describe your business interests.*

Do you own any government or corporate bonds, or other negotiable and non-negotiable instruments?*

Negotiable instruments include personal checks, cashiers’ checks, promissory notes, and money orders. Non-negotiable instruments are those you cannot transfer to someone by signing or delivering them.

Yes

Describe the bonds and other instruments.*

Do you have a retirement or pension account?*

Examples: Interests in IRA, ERISA, Keogh, 401(k), 403(b), thrift savings accounts, or other pension or profit-sharing plans.

Yes

How many retirement accounts do you have?*

Type of first retirement account?*

Value of first retirement account?*

Type of second retirement account?*

Value of second retirement account?*

Type of third retirement account?*

Value of third retirement account?*

Type of fourth retirement account?*

Value of fourth retirement account?*

Do you have any security deposits or prepayments?*

Your share of all unused deposits you have made so that you may continue service or use from a company. Examples: Agreements with landlords, prepaid rent, public utilities (electric, gas, water), telecommunications companies, or others.

Yes

How many deposits or prepayments do you have?

Type of first deposit or prepayment?*

Value of first deposit or prepayment?*

Type of second deposit or prepayment?*

Value of second deposit or prepayment?*

Type of third deposit or prepayment?*

Value of third deposit or prepayment?*

Do you have any certificates of deposit?*

Yes

What is the name of the financial institution for the CD?*

What is the cash-out value of the CD (if any)?*

Do You have an annuity?*

Yes

What is the value of the annuity?*

Do You have an interest in an education IRA?*

List all interests in an education IRA, in an account in a qualified ABLE program, or under a qualified state tuition program.

Yes

What is the value of the education IRA?*

Are you the beneficiary of a trust?*

Yes

Describe the trust.*

Do you have any equitable or future interests, or any beneficial rights or powers?*

Yes

Describe all equitable or future interests, or beneficial rights or powers you have.*

1. Your Information 2. Spouse Information 3. Dependents 4. Mobile Home 5. Real Property 6. Vehicles 7. Other Vehicles 8. Personal Property 9. Financial Assets 10. Investment Assets 11. Other Assets 12. Business Assets 13. Secured Creditors 14. Unsecured Creditors 1-10 15. Unsecured Creditors 11-20 16. Unsecured Creditors 21-30 17. Unsecured Creditors 31-40 18. Unsecured Creditors 41-50 19. Your Income 20. Spouse Income 21. Past Income 22. Household Expenses 23. Financial Affairs

Do you have intellectual property, patents, copyrights or trademarks?*

Examples: Internet domain names, websites, proceeds from royalties and licensing agreements

Yes

Describe Intellectual Property*

Do You have any licenses, franchises, or other general intangibles?*

Examples: Building permits, exclusive licenses, cooperative association holdings, liquor licenses, and professional licenses.

Yes

Describe Licenses and Franchises.*

Do You have the right to receive a tax refund?*

Examples: Past due or lump sum alimony, spousal support, child support, maintenance, divorce settlement, and property settlement.

Yes

Describe all tax refunds you are entitled to.*

Are you entitled to receive family support?*

Yes

Describe all family support you are entitled to.*

Does anyone else owe you money?*

Examples: Unpaid wages, disability insurance payments, disability benefits, sick pay, vacation pay, workers’ compensation, Social Security benefits; and unpaid loans you made to someone else.

Yes

Describe all other money that is owed to you.*

Do You have an interest in an insurance policy with cash value?*

Examples: Health, disability, or life insurance; health savings account (HSA); credit, homeowner’s, or renter’s insurance.

Yes

Describe all insurance policies you have an interest in.*

Are you expecting an inheritance?*

If you are the beneficiary of a living trust, expect proceeds from a life insurance policy, or are currently entitled to receive property because someone has died.

Yes

Describe all inheritances you have an interest in.*

Do you have a right to file a claim against anyone?*

Examples: Accidents, employment disputes, insurance claims, or rights to sue.

Yes

Describe all third-party claims you have an interest in.*

Do you have any other contingent claims?*

Yes

Describe all other contingent claims you have an interest in.*

Do you have any other assets not already listed?*

Yes

Describe all other assets you have an interest in and not already listed.*

1. Your Information 2. Spouse Information 3. Dependents 4. Mobile Home 5. Real Property 6. Vehicles 7. Other Vehicles 8. Personal Property 9. Financial Assets 10. Investment Assets 11. Other Assets 12. Business Assets 13. Secured Creditors 14. Unsecured Creditors 1-10 15. Unsecured Creditors 11-20 16. Unsecured Creditors 21-30 17. Unsecured Creditors 31-40 18. Unsecured Creditors 41-50 19. Your Income 20. Spouse Income 21. Past Income 22. Household Expenses 23. Financial Affairs

Have you owned or had an interest in a business (including self-employment) in the last 4 years?*

Yes

Describe what interests you had in any business in the last 4 years.*

Do you own or have any legal or equitable interest in any business-related property?*

Yes

Describe all legal or equitable interests in any business related property.*

Do you have any accounts receivable or commissions you have already earned?*

Yes

Describe all accounts receivable or commissions you have already earned.*

Do you own any office equipment, furnishings, and supplies?*

Examples: Business-related computers, software, modems, printers, copiers, fax machines, rugs, telephones, desks, chairs, and electronic devices.

Yes

Describe all all office equipment, furnishings, and supplies you own.*

Do you own any machinery, fixtures, equipment, supplies you use in business, and tools of your trade?*

Examples: Business-related computers, software, modems, printers, copiers, fax machines, rugs, telephones, desks, chairs, and electronic devices.

Yes

Describe all all machinery, fixtures, equipment, supplies you use in business, and tools of your trade.*

Do you own any inventory?*

Examples: Business-related computers, software, modems, printers, copiers, fax machines, rugs, telephones, desks, chairs, and electronic devices.

Yes

Describe the inventory.*

Do you have interests in partnerships or joint ventures?*

Examples: Business-related computers, software, modems, printers, copiers, fax machines, rugs, telephones, desks, chairs, and electronic devices.

Yes

Describe your interests in all partnerships and joint ventures.*

Do you own any customer lists, mailing lists, or other compilations?*

Examples: Business-related computers, software, modems, printers, copiers, fax machines, rugs, telephones, desks, chairs, and electronic devices.

Yes

Describe all customer lists, mailing lists, and other compilations you own.*

Do you own any business-related property you did not already list?*

Examples: Business-related computers, software, modems, printers, copiers, fax machines, rugs, telephones, desks, chairs, and electronic devices.

Yes

Describe any other business-related property you own.*

1. Your Information 2. Spouse Information 3. Dependents 4. Mobile Home 5. Real Property 6. Vehicles 7. Other Vehicles 8. Personal Property 9. Financial Assets 10. Investment Assets 11. Other Assets 12. Business Assets 13. Secured Creditors 14. Unsecured Creditors 1-10 15. Unsecured Creditors 11-20 16. Unsecured Creditors 21-30 17. Unsecured Creditors 31-40 18. Unsecured Creditors 41-50 19. Your Income 20. Spouse Income 21. Past Income 22. Household Expenses 23. Financial Affairs

Do you have any secured debts not already listed?*

Yes

What is the name of the secured creditor?*

What is this secured creditor's address?*

Street Address Address Line 2 City State ZIP Code

What is the account number for this secured creditor?*

How much is owed to this secured creditor?*

What is the monthly payment to this secured creditor?*

Describe what property this debt secures.*

1. Your Information 2. Spouse Information 3. Dependents 4. Mobile Home 5. Real Property 6. Vehicles 7. Other Vehicles 8. Personal Property 9. Financial Assets 10. Investment Assets 11. Other Assets 12. Business Assets 13. Secured Creditors 14. Unsecured Creditors 1-10 15. Unsecured Creditors 11-20 16. Unsecured Creditors 21-30 17. Unsecured Creditors 31-40 18. Unsecured Creditors 41-50 19. Your Income 20. Spouse Income 21. Past Income 22. Household Expenses 23. Financial Affairs

Unsecured Creditors

List all unsecured creditors in your name. Unsecured debts include things like credit cards, revolving accounts, personal loans, student loans, medical bills, bank overdrafts, repossession deficiencies, past due rent, utility debts, trade debts, and collections.

Do you have a credit report?*

Yes

If you have a full credit report (e.g. from www.annualcreditreport.com) you can upload that below. If you upload a creditor report with all your creditors, you do not need to fill out the creditors separately.

Upload credit reports here.

Max. file size: 3 GB.

Do you need to list creditors that were not on your credit report?*

Yes

Unsecured Creditor 1

What is the name of the unsecured creditor?

What is the address of the unsecured creditor?

Street Address Address Line 2 City State ZIP Code

What is the account number?

How much is owed?

When was the debt incurred?

MM slash DD slash YYYY

Unsecured Creditor 2

What is the name of the unsecured creditor?

What is the address of the unsecured creditor?

Street Address Address Line 2 City State ZIP Code

What is the account number?

How much is owed?

When was the debt incurred?

MM slash DD slash YYYY

Unsecured Creditor 3

What is the name of the unsecured creditor?

What is the address of the unsecured creditor?

Street Address Address Line 2 City State ZIP Code

What is the account number?

How much is owed?

When was the debt incurred?

MM slash DD slash YYYY

Unsecured Creditor 4

What is the name of the unsecured creditor?

What is the address of the unsecured creditor?

Street Address Address Line 2 City State ZIP Code

What is the account number?

How much is owed?

When was the debt incurred?

MM slash DD slash YYYY

Unsecured Creditor 5

What is the name of the unsecured creditor?

What is the address of the unsecured creditor?

Street Address Address Line 2 City State ZIP Code

What is the account number?

How much is owed?

When was the debt incurred?

MM slash DD slash YYYY

Unsecured Creditor 6

What is the name of the unsecured creditor?

What is the address of the unsecured creditor?

Street Address Address Line 2 City State ZIP Code

What is the account number?

How much is owed?

When was the debt incurred?

MM slash DD slash YYYY

Unsecured Creditor 7

What is the name of the unsecured creditor?

What is the address of the unsecured creditor?

Street Address Address Line 2 City State ZIP Code

What is the account number?

How much is owed?

When was the debt incurred?

MM slash DD slash YYYY

Unsecured Creditor 8

What is the name of the unsecured creditor?

What is the address of the unsecured creditor?

Street Address Address Line 2 City State ZIP Code

What is the account number?

How much is owed?

When was the debt incurred?

MM slash DD slash YYYY

Unsecured Creditor 9

What is the name of the unsecured creditor?

What is the address of the unsecured creditor?

Street Address Address Line 2 City State ZIP Code

What is the account number?

How much is owed?

When was the debt incurred?

MM slash DD slash YYYY

Unsecured Creditor 10

What is the name of the unsecured creditor?

What is the address of the unsecured creditor?

Street Address Address Line 2 City State ZIP Code

What is the account number?

How much is owed?

What is the name of the unsecured creditor?

What is the address of the unsecured creditor?

Street Address Address Line 2 City State ZIP Code

What is the account number?

What is the name of the unsecured creditor?

What is the address of the unsecured creditor?

Street Address Address Line 2 City State ZIP Code

What is the account number?

What is the name of the unsecured creditor?

What is the address of the unsecured creditor?

Street Address Address Line 2 City State ZIP Code

What is the account number?

What is the name of the unsecured creditor?

What is the address of the unsecured creditor?

Street Address Address Line 2 City State ZIP Code

What is the account number?

How much is owed?

When was the debt incurred?

MM slash DD slash YYYY

1. Your Information 2. Spouse Information 3. Dependents 4. Mobile Home 5. Real Property 6. Vehicles 7. Other Vehicles 8. Personal Property 9. Financial Assets 10. Investment Assets 11. Other Assets 12. Business Assets 13. Secured Creditors 14. Unsecured Creditors 1-10 15. Unsecured Creditors 11-20 16. Unsecured Creditors 21-30 17. Unsecured Creditors 31-40 18. Unsecured Creditors 41-50 19. Your Income 20. Spouse Income 21. Past Income 22. Household Expenses 23. Financial Affairs

Income

What is your employment status?*

Employed

Self-employed

Unemployed

What is the name of your employer?*

What is your work telephone number?*

What is your work address?*

Street Address Address Line 2 City State ZIP Code

What is your job title?*

How long have you been employed at this job?*

Upload all paystubs you have received from this job in the last 6 months.

Max. file size: 20 MB.

Are you employed anywhere else?*

Yes

What is the name of your second employer?*

What is your work telephone number of your second employer?*

What is your work address of your second employer?*

Street Address Address Line 2 City State ZIP Code

What is your job title with your second employer?*

How long have you been employed at this second job?*

Upload all paystubs you have received from this job in the last 6 months.

Max. file size: 20 MB.

What kind of self-employment do you perform?*

In what business form do you operate?*

What business name do you operate under?*

Upload your profit and loss statement for the last 6 months.

Max. file size: 20 MB.

Do you receive income from any source other than employment income?*

Yes

What is your monthly income from this source (or sources)?*

Upload any documents showing the source and amounts of income you receive.

Max. file size: 20 MB.

1. Your Information 2. Spouse Information 3. Dependents 4. Mobile Home 5. Real Property 6. Vehicles 7. Other Vehicles 8. Personal Property 9. Financial Assets 10. Investment Assets 11. Other Assets 12. Business Assets 13. Secured Creditors 14. Unsecured Creditors 1-10 15. Unsecured Creditors 11-20 16. Unsecured Creditors 21-30 17. Unsecured Creditors 31-40 18. Unsecured Creditors 41-50 19. Your Income 20. Spouse Income 21. Past Income 22. Household Expenses 23. Financial Affairs

Spouse Income

What is your spouse's employment status?*

Employed

Self-employed

Unemployed

What is the name of your spouse's employer?*

What is your spouse's work telephone number?*

What is your spouse's work address?*

Street Address Address Line 2 City State ZIP Code

What is your spouse's job title?*

How long has your spouse been employed at this job?*

Upload all paystubs your spouse has received from this job in the last 6 months.

Max. file size: 20 MB.

Is your spouse employed anywhere else?*

Yes

What is the name of your spouse's second employer?*

What is your spouse's work telephone number of your spouse's second employer?*

What is the work address of your spouse's second employer?*

Street Address Address Line 2 City State ZIP Code

What is the job title with your spouse's second employer?*

How long has your spouse been employed at this second job?*

Upload all paystubs your spouse has received from this second job in the last 6 months.

Max. file size: 20 MB.

What kind of self-employment does your spouse perform?*

In what business form does your spouse operate?*

What business name does your spouse operate under?*

Upload your spouse's profit and loss statement for the last 6 months.

Max. file size: 20 MB.

Does your spouse receive icome from any source other than employment income?*

Yes

Do you receive income from other than employment or business income (e.g social security, workers comp, VA disability, food stamps, gambling, etc.)?

What is the source of your spouse's other income?*

What is your monthly income from this source (or sources)?*

Upload any documents showing the source and amounts of income your spouse receives.

Max. file size: 20 MB.

1. Your Information 2. Spouse Information 3. Dependents 4. Mobile Home 5. Real Property 6. Vehicles 7. Other Vehicles 8. Personal Property 9. Financial Assets 10. Investment Assets 11. Other Assets 12. Business Assets 13. Secured Creditors 14. Unsecured Creditors 1-10 15. Unsecured Creditors 11-20 16. Unsecured Creditors 21-30 17. Unsecured Creditors 31-40 18. Unsecured Creditors 41-50 19. Your Income 20. Spouse Income 21. Past Income 22. Household Expenses 23. Financial Affairs

Within the last 8 years, did you ever live with a spouse or legal equivalent in a community property state or territory?*

Yes

(Community property states and territories include Arizona, California, Idaho, Louisiana, Nevada, New Mexico, Puerto Rico, Texas, Washington, and Wisconsin.)

Did you receive any income during this year or the two previous calendar years?*

Examples include alimony; child support; Social Security, unemployment, and other public benefit payments; pensions; rental income; interest; dividends; money collected from lawsuits; royalties; and gambling and lottery winnings.

Yes

From January 1 of current year until the date you file for bankruptcy:

Source of first income?*

Gross income from first source?*

Source of second income?*

Gross income from second source?*

Source of third income?*

Gross income from third source?*

For last calendar year:

Source of first income?*

Gross income from first source?*

Source of second income?*

Gross income from second source?*

Source of third income?*

Gross income from third source?*

Did your spouse receive any income during this year or the two previous calendar years?*

Yes

For the calendar year before that:

Source of first income?*

Gross income from first source?*

Source of second income?*

Gross income from second source?*

Source of third income?*

Gross income from third source?*

From January 1 of current year until the date you file for bankruptcy:

Source of first income?*

Gross income from first source?*

Source of second income?*

Gross income from second source?*

Source of third income?*

Gross income from third source?*

For last calendar year:

Source of first income?*

Gross income from first source?*

Source of second income?*

Gross income from second source?*

Source of third income?*

Gross income from third source?*

For the calendar year before that:

Source of first income?*

Gross income from first source?*

Source of second income?*

Gross income from second source?*

Source of third income?*

Gross income from third source?*

1. Your Information 2. Spouse Information 3. Dependents 4. Mobile Home 5. Real Property 6. Vehicles 7. Other Vehicles 8. Personal Property 9. Financial Assets 10. Investment Assets 11. Other Assets 12. Business Assets 13. Secured Creditors 14. Unsecured Creditors 1-10 15. Unsecured Creditors 11-20 16. Unsecured Creditors 21-30 17. Unsecured Creditors 31-40 18. Unsecured Creditors 41-50 19. Your Income 20. Spouse Income 21. Past Income 22. Household Expenses 23. Financial Affairs

Household Expenses

Rental or mortgage payment?*

Home Maintenance, repair, and upkeep expenses?*

Homeowner association or condominium dues?*

Additional mortgage payments for residence, such as home equity loans?*

Electricity, heat, and natural gas?*

Water, sewer, and garbage collection?*

Telephone, cell phone, internet, satellite, and cable?*

Food and housekeeping supplies?*

Childcare and children's education costs?*

Clothing, laundry, and dry cleaning?*

Personal care products and services?*

Medical and dental expenses?*

Transportation? (include gas, maintenance, bus, train, but not payments)*

Entertainment, clubs, recreation, newspapers, magazines, and books?*

Charitable contributions and religious donations?*

Life insurance? (Not deducted from wages)*

Health insurance? (Not deducted from wages)*

Vehicle insurance?*

Taxes? (Not deducted from wages)*

Besides payments you have already listed, are you making installment payments on anything else?*

Yes

What other installment payments are you making?*

Other expenses? (not already listed)

1. Your Information 2. Spouse Information 3. Dependents 4. Mobile Home 5. Real Property 6. Vehicles 7. Other Vehicles 8. Personal Property 9. Financial Assets 10. Investment Assets 11. Other Assets 12. Business Assets 13. Secured Creditors 14. Unsecured Creditors 1-10 15. Unsecured Creditors 11-20 16. Unsecured Creditors 21-30 17. Unsecured Creditors 31-40 18. Unsecured Creditors 41-50 19. Your Income 20. Spouse Income 21. Past Income 22. Household Expenses 23. Financial Affairs

Within the past 12 months, did you make a payment on a debt you owed anyone who was an insider?*

Yes

To whom did you make the payment, the reason for the payment and the amount?*

Within the past 12 months, did you make any payments or transfer any property on account of a debt that benefited an insider? Include payments on debts guaranteed or cosigned by an insider.*

Yes

To whom did you make the payment, the reason for the payment and the amount?*

Within the past 12 months, were you a party in any lawsuits, court action, or administrative proceeding? List all such matters, including personal injury cases, small claims actions, divorces, collection suits, paternity actions, support or custody modifications, and contract disputes.*

Yes

Describe the lawsuit.*

Within the past 12 months, was any of your property repossessed, foreclosed, garnished, attached, seized, or levied?*

Yes

Describe what property was taken.*

Within the past 90 days, did any creditor, including a bank or financial institution, set off any amounts from your accounts or refuse to make a payment because you owed a debt?*

Yes

Describe what property was taken.*

Within the past 12 months, was any of your property in the possession of an assignee for the benefit of a court-appointed receiver, a custodian, or another official?*

Yes

Describe the assignment.*

Within the past 24 months, did you give any gifts with a total value of more than $600 per person?*

Yes

Describe the gift.*

Within the past 24 months, did you give any gifts or contributions with a total value of more than $600 to any charity?*

Yes

Describe the charitable gift.*

Within the past 12 months, did you lose anything because of fire, theft, other disaster, or gambling?*

Yes

Describe the loss.*

Within the past 12 months, did you or anyone else acting or your behalf pay or transfer any property to anyone who promised to help you deal with your creditors or to make payments to your creditors?*

Yes

Describe who helped you deal with creditors.*

Within the past 24 months, did you sell, trade, or otherwise transfer any property to anyone, other than property transferred in the ordinary course of business or financial affairs? Include both outright transfers and transfers made as security (such as the granting of a security interest or mortgage on your property). Do not include gifts and transfers that you have already listed on this statement?*

Yes

Describe what property was sold or transferred.*

Within the past 10 years, did you transfer any property to a self-settled trust or similar device of which you are a beneficiary? (These are often called asset protection devices.)*

Yes

Describe what property was transferred into the trust.*

Within the past 12 months, were any financial accounts or instruments held in your name, or for your benefit, closed, sold, moved, or transferred? (include checking, savings, money market, or other financial accounts, certificates of deposit, shares in banks, credit unions, brokerage house, pension funds, cooperatives, associations, and other financial institutions.*

Yes

Describe the the closed bank accounts.*

Do you now have, or did you have within the past 12 months, any safe deposit box or other depository for securities, cash, or other valuables?*

Yes

Describe the contents of the safe deposit box.*

Have you stored property in a storage unit or place other than your home within the past 12 months?*

Yes

Describe the contents of the stored in another location.*

Are you storing, or holding in trust any property belonging to someone else?*

Yes

Describe the property you are storing for someone else.*

Has any governmental unit notified you that you may be liable or potentially liable under or in violation of an environmental law?*

Yes

Describe the environmental notice you received.*

Have you notified any governmental unit of any release of hazardous material?*

Yes

Describe the notice you have given.*

Have you been a party in any judicial or administrative proceeding under any environmental law? Include settlements and orders.*

Yes

Describe the environmental proceeding.*

With the past 4 years, did you own a business or have any connections to any business?*

Yes

Describe your business relationship(s) in the last 4 years*

Within the past 24 months, did you give a financial statement to anyone about your business? Include all financial institutions, creditors, or other parties.*

Yes

Describe all parties to whom you have given a financial statement.*

Certification*

By checking this box, I certify that that I have answered all the foregoing questions truthfully to the best of my knowledge and ability.