Bankruptcy Questionnaire

What is your name?

First Middle Last Suffix

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

Yes

No

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?

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

What is your physical address?

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?

Yes

No

Prior Address #1

Street Address Address Line 2 City State ZIP Code

Address #1 move in date?

Address #1 move out date?

Have you lived anywhere else in the last 3 years?

Yes

No

Prior Address #2

Street Address Address Line 2 City State ZIP Code

Address #2 move in date?

Address #2 move out date?

Have you lived anywhere else in the last 3 years?

Yes

No

Prior Address #3

Street Address Address Line 2 City State ZIP Code

Address #3 move in date?

Address #3 move out date?

Do you have a different mailing address?

Yes

No

What is your mailing address?

Street Address Address Line 2 City State ZIP Code

Have you ever filed bankruptcy before?

Yes

No

When did you file your last bankruptcy?

What Chapter?

Did you receive a discharge?

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

Yes

No

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

Dependent's name?

Dependent's relationship to you?

Dependent's age?

Second dependent's name?

Second dependent's relationship to you?

Second dependent's age?

Third dependent's name?

Third dependent's relationship to you?

Third dependent's age?

Fourth dependent's name?

Fourth dependent's relationship to you?

Fourth dependent's age?

Fifth dependent's name?

Fifth dependent's relationship to you?

Fifth dependent's age?

Do you have any cash on hand?

Yes

No

How much cash do you have on hand?

Do you have any financial accounts?

Yes

No

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?

Do you have any secured debts not already listed?

Yes

No

What is the name of the secured creditor?

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.

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

No

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: 512 MB.

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

Yes

No

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?

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?

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?

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?

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?

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?

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?

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?

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?

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?

When was the debt incurred?

Do you have any additional unsecured creditors to add?

Yes

No

Unsecured Creditors - Continued

List any additional unsecured creditors in this section.

Unsecured Creditor 11

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?

Unsecured Creditor 12

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?

Unsecured Creditor 13

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?

Unsecured Creditor 14

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?

Unsecured Creditor 15

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?

Unsecured Creditor 16

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?

Unsecured Creditor 17

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?

Unsecured Creditor 18

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?

Unsecured Creditor 19

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?

Unsecured Creditor 20

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?

Do you have any additional unsecured creditors to add?

Yes

No

Unsecured Creditors - Continued

Unsecured Creditor 21

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?

Unsecured Creditor 22

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?

Unsecured Creditor 23

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?

Unsecured Creditor 24

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?

Unsecured Creditor 25

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?

Unsecured Creditor 26

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?

Unsecured Creditor 27

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?

Unsecured Creditor 28

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?

Unsecured Creditor 29

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?

Unsecured Creditor 30

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?

Do you have any additional unsecured creditors to add?

Yes

No

Unsecured Creditors - Continued

Unsecured Creditor 31

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?

Unsecured Creditor 32

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?

Unsecured Creditor 33

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?

Unsecured Creditor 34

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?

Unsecured Creditor 35

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?

Unsecured Creditor 36

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?

Unsecured Creditor 37

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?

Unsecured Creditor 38

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?

Unsecured Creditor 39

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?

Unsecured Creditor 40

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?

Do you have any additional unsecured creditors to add?

Yes

No

Unsecured Creditors - Continued

Unsecured Creditor 41

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?

Unsecured Creditor 42

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?

Unsecured Creditor 43

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?

Unsecured Creditor 44

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?

Unsecured Creditor 45

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?

Unsecured Creditor 46

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?

Unsecured Creditor 47

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?

Unsecured Creditor 48

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?

Unsecured Creditor 49

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?

Unsecured Creditor 50

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?

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

No

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

No

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 this income?

What is your monthly income from this source?

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

Max. file size: 20 MB.

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

No

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

No

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?

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

Max. file size: 20 MB.

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

Yes

No

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

Did you receive any income, other than employment, during this year or the two previous calendar years?

Yes

No

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?

Did your spouse receive any income, other than employment, during this year or the two previous calendar years?

Yes

No

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?

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)

Installment payments? (not already listed)

Other expenses? (not already listed)

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.