Bankruptcy Questionnaire - The Document People [PDF]

Bankruptcy Questionnaire

 Yes  No

1. Have you ever filed for Bankruptcy before?

If you answered YES please provide us with information about your previously filed Bankruptcy. Case Number: __________________________________________________ Date Filed: ____________________________________________________ Court Info: ____________________________________________________ Chapter: ______________________________________________________ 2. Has your landlord filed a judgment against you, the debtor?

 Yes  No

3. Do you own a business?

 Yes  No

4. Are you physically disabled, incapacitated or an active military?

 Yes  No

5. Do you own/have possession of any property that poses or is alleged to pose threat of imminent and identifiable harm to public health or safety?

 Yes  No

If you

6. Do you have a spouse or former spouse (within the last 8 years)?

 Yes  No

If YES, please provide name of any spouse(s) or former spouse(s): ____________________________________________________________________________ Name(s) 7. Which exemption would you like us to use to exempt your personal property? Please refer to the EXEMPTION pages next for a list assets and exemptions

 State  Federal 

8. Do you own real estate property? Yes If you have responded YES, please pick the appropriate real estate exemption from the plan you have selected (see real estate exemptions in the EXEMPTION pages, next to the home icon

____________________________________ All answers in this questionnaire were provided by me I did NOT receive any legal advice by the store’s staff

 No )

If you are reading this questionnaire electronically, you’ll find plenty of sticky notes to help

BANKRUPTCY CHECK LIST To get started, you will need… ________

1. MEANS TEST WORKSHEET – This must be completed to the best of your knowledge and returned to us with your completed bankruptcy workbook.

________

2. BANKRUPTCY WORKBOOK – This must be completed as accurately as possible and to the best of your knowledge. Return these two workbooks to The Document People, when completed. Complete as much as you can. We are not allowed to sit with you and help you complete it. We will review for accuracy and completion.

Meanwhile… ________

3. CONTACT A CREDIT COUNSELOR – Preferably a Non-profit agency; we refer all of our customers to the following agency:

My BK NOW Phone 877.692.5669, www.mybknow.com. Let them know you are filing Bankruptcy and need to get your Credit Counseling Completion Certificate.

________

4. BANKRUPTCY PETITION – Once we call you to inform you that your documents are ready to be signed, it will be your responsibility to double check our work. If you fail to do so, other charges will apply.

Once prepared and ready to file, make sure you have the following: ________ ________ ________ ________ ________ ________ ________

A. Petition plus 1 copy B. Means Test C. Proof of income for the last 60 days.

You’ll need pay stubs for the last 60 days. If 0$ income provide a letter stating so.

D. Credit Counseling Completion Certificate E. $306 Cash F. Identification Card and Social Security Card (on same occasions these IDs are required) G. Make sure you have filed appropriate tax returns for the last 3 years for both Federal and State, or last filed tax return.

Attending the bankruptcy hearing, you will need: ________ ________

Identification Card and Social Security Card For your convenience, keep copies of everything you have filed

The following item must be filed with the court before the court can discharge your bk ________

Debtor Education Course Completion Certificate. This is the second course you must complete with your credit counselor.

This check list was created by The Document People to assist our customers with their bankruptcy procedure. This information is not and should not be considered legal advice.

Checklist

Statement of Your Current Monthly Income Be as complete and accurate as possible. If two married people are filing together, both are equally responsible for being accurate. If more space is needed, attach a separate sheet to this form. Include the line number to which the additional information applies. On the top of any additional pages, write your name and case number (if known). If you believe that you are exempted from a presumption of abuse because you do not have primarily consumer debts or because of qualifying military service, complete and file Statement of Exemption from Presumption of Abuse Under § 707(b)(2) (Official Form 122A-1Supp) with this form. Part 1:

Calculate Your Current Monthly Income

1. What is your marital and filing status? Check one only.

  

Not married. Fill out Column A, lines 2-11. Married and your spouse is filing with you. Fill out both Columns A and B, lines 2-11. Married and your spouse is NOT filing with you. You and your spouse are:

 

Living in the same household and are not legally separated. Fill out both Columns A and B, lines 2-11. Living separately or are legally separated. Fill out Column A, lines 2-11; do not fill out Column B. By checking this box, you declare under penalty of perjury that you and your spouse are legally separated under nonbankruptcy law that applies or that you and your spouse are living apart for reasons that do not include evading the Means Test requirements. 11 U.S.C. § 707(b)(7)(B).

Fill in the average monthly income that you received from all sources, derived during the 6 full months before you file this bankruptcy case. 11 U.S.C. § 101(10A). For example, if you are filing on September 15, the 6-month period would be March 1 through August 31. If the amount of your monthly income varied during the 6 months, add the income for all 6 months and divide the total by 6. Fill in the result. Do not include any income amount more than once. For example, if both spouses own the same rental property, put the income from that property in one column only. If you have nothing to report for any line, write $0 in the space. Column A

Column B

Debtor 1

Debtor 2 or non-filing spouse

2. Your gross wages, salary, tips, bonuses, overtime, and commissions (before all payroll deductions).

$_________

$__________

3. Alimony and maintenance payments. Do not include payments from a spouse if Column B is filled in.

$_________

$__________

4. All amounts from any source which are regularly paid for household expenses of you or your dependents, including child support. Include regular contributions from an unmarried partner, members of your household, your dependents, parents, and roommates. Include regular contributions from a spouse only if Column B is not filled in. Do not include payments you listed on line 3.

$_________

$__________

$_________

$__________

$_________

$__________

$_________

$__________

5. Net income from operating a business, profession, or farm Gross receipts (before all deductions) Ordinary and necessary operating expenses Net monthly income from a business, profession, or farm 6. Net income from rental and other real property Gross receipts (before all deductions) Ordinary and necessary operating expenses Net monthly income from rental or other real property

Debtor 1

$______

Debtor 2

$______

– $______ – $______ $______ Debtor 1

$______

Copy

$______ here Debtor 2

$______

– $______ – $______ Copy

$______

$______ here

7. Interest, dividends, and royalties

Page 1

Column B Debtor 2 or non-filing spouse

Column A Debtor 1

8. Unemployment compensation

$__________

$___________

$__________

$___________

______________________________________

$_________

$___________

______________________________________

$_________

$___________

+ $_________

+ $___________

Do not enter the amount if you contend that the amount received was a benefit under the Social Security Act. Instead, list it here:.................................  For you..................................................................................... $______________ For your spouse..................................................................... $______________ 9. Pension or retirement income. Do not include any amount received that was a benefit under the Social Security Act. 10. Income from all other sources not listed above. Specify the source and amount. Do not include any benefits received under the Social Security Act or payments received as a victim of a war crime, a crime against humanity, or international or domestic terrorism. If necessary, list other sources on a separate page and put the total below.

Total amounts from separate pages, if any. 11. Calculate your total current monthly income. Add lines 2 through 10 for each column. Then add the total for Column A to the total for Column B.

$_________

+

$___________

=

$__________ Total current monthly income

Part 2:

Determine Whether the Means Test Applies to You

12. Calculate your current monthly income for the year. Follow these steps: 12a.

12b.

Copy your total current monthly income from line 11. ..................................................................................... Copy line 11 here

$__________

Multiply by 12 (the number of months in a year).

x 12

The result is your annual income for this part of the form.

12b.

$__________

13. Calculate the median family income that applies to you. Follow these steps:

Fill in the number of people in your household >>>>>

Now compare the amount in 12b. with the Median Income for your family size to the right ===================================> If your Median Income is lower, then you qualify. If it's higher you'll be able to claim exemptions and cost of living adjustements to reduce it. Ask a member of our staff to provide you with the supplement.

¯¯¯¯¯

Page 2

MEDIAN INCOME CALIFORNIA Family size Income 1 person $50,519 2 people $66,458 3 people $70,732 4 people * $81,740 * Add $8,100 for each individual in excess of 4

District of: (ex: Central California).

Division of:

Central California is the district for Los Angeles and Orange Counties Name of Debtor (if individual, enter Last, First, Middle):

Name of Joint Debtor (spouse) (Last, First, Middle):

Social Security or Individual-Taxpayer I.D. (ITIN)/Complete EIN (if more than one, state all):

Social Security or Individual-Taxpayer I.D. (ITIN) /Complete EIN (if more than one, state all):

Street Address of Debtor (No. and Street, City, and State):

Street Address of Joint Debtor (No. and Street, City, and State):

County of Residence:

County of Residence:

Mailing Address of Debtor (if different from street address):

Mailing Address of Debtor (if different from street address):

Location of Principal Assets of Business Debtor (if different from street address above):

Type of Debtor (Form of Organization) (Check one box)

Nature of Business (Check one box)  

Health Care Business Single Asset Real Estate as defined in 11 U.S.C. § 101(51B) Railroad Stockbroker Commodity Broker Clearing Bank Other

Nature of Debts (Check one box) 

Debts are primarily consumer debts, defined in 11 U.S.C. § 101(8) as “incurred by individual primarily for a personal, family, or household purpose.” Debts are debts primarily business debts.

   

Individual (includes Joint Debtors) Corporation (includes LLC and LLP) Partnership Other (If debtor is not one of the above entities, check this box and state type of entity below.)

 

Debtor estimates that funds will be available for distribution to unsecured creditors. Debtor estimates that, after any exempt property is excluded and administrative expenses paid, there will be no funds available for distribution to unsecured creditors.

Estimated Number of Creditors          

1-49 50-99 100-199 200-999 1,000-5,000 5,001-10,000 10,001-25,000 25,001-50,000 50,001-100,000 Over 100,000

    

Estimated Assets          



Estimated Liabilities

1-49 50-99 100-199 200-999 1,000-5,000 5,001-10,000 10,001-25,000 25,001-50,000 50,001-100,000 Over 100,000

Page 3

         

1-49 50-99 100-199 200-999 1,000-5,000 5,001-10,000 10,001-25,000 25,001-50,000 50,001-100,000 Over 100,000

Schedules A and B: Your Properties In each category, separately list and describe items. List an asset only once. If an asset fits in more than one category, list the asset in the category where you think it fits best. Be as complete and accurate as possible. If two married people are filing together, both are equally responsible for supplying correct information. If more space is needed, attach a separate sheet to this form. On the top of any additional pages, write your name and case number (if known). Answer every question. Part 1:

Describe Each Residence, Building, Land, or Other Real Estate You Own or Have an Interest In

1. Do you own or have any legal or equitable interest in any residence, building, land, or similar property?

 

No. Go to Part 2. Yes. Where is the property? What is the property? Check all that apply.

1.1. _________________________________________ Street address, if available, or other description

_________________________________________

_________________________________________ City State ZIP Code

       

Single-family home Duplex or multi-unit building Condominium or cooperative

Do not deduct secured claims or exemptions. Put the amount of any secured claims on Schedule D: Creditors Who Have Claims Secured by Property.

Manufactured or mobile home

Current value of the entire property?

Current value of the portion you own?

Land

$________________

$_______________

Investment property Timeshare Other __________________________________

Describe the nature of your ownership interest (such as fee simple, tenancy by the entireties, or a life estate), if known.

Who has an interest in the property? Check one. _________________________________________ County

 Debtor 1 only  Debtor 2 only  Debtor 1 and Debtor 2 only  At least one of the debtors and another

__________________________________________

 Check if this is community property (see instructions)

Other information you wish to add about this item, such as local property identification number: _______________________________ If you own or have more than one, list here: What is the property? Check all that apply. 1.2. ________________________________________ Street address, if available, or other description

________________________________________

________________________________________ City State ZIP Code

       

Single-family home Duplex or multi-unit building Condominium or cooperative Manufactured or mobile home

Current value of the entire property?

Current value of the portion you own?

Land

$________________

$_________________

Investment property Timeshare Other __________________________________

Who has an interest in the property? Check one. ________________________________________ County

Do not deduct secured claims or exemptions. Put the amount of any secured claims on Schedule D: Creditors Who Have Claims Secured by Property.

 Debtor 1 only  Debtor 2 only  Debtor 1 and Debtor 2 only  At least one of the debtors and another

Describe the nature of your ownership interest (such as fee simple, tenancy by the entireties, or a life estate), if known. __________________________________________

 Check if this is community property (see instructions)

Other information you wish to add about this item, such as local property identification number: _______________________________

Page 4

What is the property? Check all that apply. 1.3. ________________________________________ Street address, if available, or other description

________________________________________

________________________________________ City State ZIP Code

       

Single-family home Duplex or multi-unit building Condominium or cooperative Manufactured or mobile home Land

Current value of the entire property?

Current value of the portion you own?

$________________

$_________________

Investment property Timeshare Other __________________________________

Who has an interest in the property? Check one. ________________________________________ County

Do not deduct secured claims or exemptions. Put the amount of any secured claims on Schedule D: Creditors Who Have Claims Secured by Property.

 Debtor 1 only  Debtor 2 only  Debtor 1 and Debtor 2 only  At least one of the debtors and another

Describe the nature of your ownership interest (such as fee simple, tenancy by the entireties, or a life estate), if known. __________________________________________

 Check if this is community property (see instructions)

Other information you wish to add about this item, such as local property identification number: _______________________________

2. Add the dollar value of the portion you own for all of your entries from Part 1, including any entries for pages

you have attached for Part 1. Write that number here. ...................................................................................... 

$_________________

Describe Your Vehicles

Part 2:

Do you own, lease, or have legal or equitable interest in any vehicles, whether they are registered or not? Include any vehicles you own that someone else drives. If you lease a vehicle, also report it on Schedule G: Executory Contracts and Unexpired Leases. 3. Cars, vans, trucks, tractors, sport utility vehicles, motorcycles

 

No Yes

3.1.

Make:

______________

Model:

______________

Year:

____________

Approximate mileage: ____________

Who has an interest in the property? Check one.

 Debtor 1 only  Debtor 2 only  Debtor 1 and Debtor 2 only  At least one of the debtors and another

Do not deduct secured claims or exemptions. Put the amount of any secured claims on Schedule D: Creditors Who Have Claims Secured by Property.

Current value of the entire property?

Current value of the portion you own?

$________________

$________________

Other information:

 Check if this is community property (see instructions)

If you own or have more than one, describe here: 3.2.

Make:

______________

Model:

______________

Year:

____________

Approximate mileage: ____________

Who has an interest in the property? Check one.

 Debtor 1 only  Debtor 2 only  Debtor 1 and Debtor 2 only  At least one of the debtors and another

Do not deduct secured claims or exemptions. Put the amount of any secured claims on Schedule D: Creditors Who Have Claims Secured by Property.

Current value of the entire property?

Current value of the portion you own?

$________________

$________________

Other information:

 Check if this is community property (see instructions)

Page 5

3.3.

Make:

______________

Model:

______________

Year:

____________

Approximate mileage: ____________

Who has an interest in the property? Check one.

 Debtor 1 only  Debtor 2 only  Debtor 1 and Debtor 2 only  At least one of the debtors and another

Do not deduct secured claims or exemptions. Put the amount of any secured claims on Schedule D: Creditors Who Have Claims Secured by Property.

Current value of the entire property?

Current value of the portion you own?

$________________

$________________

Other information:

 Check if this is community property (see instructions)

3.4.

Make:

______________

Model:

______________

Year:

____________

Approximate mileage: ____________

Who has an interest in the property? Check one.

 Debtor 1 only  Debtor 2 only  Debtor 1 and Debtor 2 only  At least one of the debtors and another

Do not deduct secured claims or exemptions. Put the amount of any secured claims on Schedule D: Creditors Who Have Claims Secured by Property.

Current value of the entire property?

Current value of the portion you own?

$________________

$________________

Other information:

 Check if this is community property (see instructions)

4. Watercraft, aircraft, motor homes, ATVs and other recreational vehicles, other vehicles, and accessories

Examples: Boats, trailers, motors, personal watercraft, fishing vessels, snowmobiles, motorcycle accessories

 

No Yes

4.1.

Make:

____________________

Model: ____________________ Year:

____________

Other information:

Who has an interest in the property? Check one.

 Debtor 1 only  Debtor 2 only  Debtor 1 and Debtor 2 only  At least one of the debtors and another  Check if this is community property (see instructions)

Do not deduct secured claims or exemptions. Put the amount of any secured claims on Schedule D: Creditors Who Have Claims Secured by Property.

Current value of the entire property?

Current value of the portion you own?

$________________

$________________

If you own or have more than one, list here: 4.2.

Make:

____________________

Model: ____________________ Year:

____________

Other information:

Who has an interest in the property? Check one.

 Debtor 1 only  Debtor 2 only  Debtor 1 and Debtor 2 only  At least one of the debtors and another  Check if this is community property (see

Do not deduct secured claims or exemptions. Put the amount of any secured claims on Schedule D: Creditors Who Have Claims Secured by Property.

Current value of the entire property?

Current value of the portion you own?

$________________

$________________

instructions)

5. Add the dollar value of the portion you own for all of your entries from Part 2, including any entries for pages

you have attached for Part 2. Write that number here ............................................................................................................................

Page 6

$_________________

Part 3:

Describe Your Personal and Household Items

Do you own or have any legal or equitable interest in any of the following items?

Current value of the portion you own? Do not deduct secured claims or exemptions.

6. Household goods and furnishings

Examples: Major appliances, furniture, linens, china, kitchenware

 

No Yes. Describe. ........

$___________________

7. 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

 

No Yes. Describe. .........

$___________________

8. Collectibles 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, collectibles  No  Yes. Describe. .........

$___________________

9. Equipment for sports and hobbies

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

 

No Yes. Describe. .........

$___________________

10. Firearms

Examples: Pistols, rifles, shotguns, ammunition, and related equipment  No  Yes. Describe. .........

$___________________

11. Clothes

Examples: Everyday clothes, furs, leather coats, designer wear, shoes, accessories

 

No Yes. Describe. .........

$___________________

12. Jewelry

Examples: Everyday jewelry, costume jewelry, engagement rings, wedding rings, heirloom jewelry, watches, gems, gold, silver

 

No Yes. Describe. .........

$___________________

13. Non-farm animals

Examples: Dogs, cats, birds, horses

 

No Yes. Describe. .........

$___________________

14. Any other personal and household items you did not already list, including any health aids you did not list

 

No Yes. Give specific information...............

$___________________

15. Add the dollar value of all of your entries from Part 3, including any entries for pages you have attached

for Part 3. Write that number here ........................................................................................................................................................ 

Page 7

$______________________

Part 4:

Describe Your Financial Assets Current value of the portion you own?

Do you own or have any legal or equitable interest in any of the following?

Do not deduct secured claims or exemptions. 16. Cash

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

 

No Yes .....................................................................................................................................................................

Cash: .......................

$__________________

17. Deposits of money

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

 

No Yes .....................

Institution name:

17.1. Checking account:

_________________________________________________________

$__________________

17.2. Checking account:

_________________________________________________________

$__________________

17.3. Savings account:

_________________________________________________________

$__________________

17.4. Savings account:

_________________________________________________________

$__________________

17.5. Certificates of deposit:

_________________________________________________________

$__________________

17.6. Other financial account:

_________________________________________________________

$__________________

17.7. Other financial account:

_________________________________________________________

$__________________

17.8. Other financial account:

_________________________________________________________

$__________________

17.9. Other financial account:

_________________________________________________________

$__________________

18. Bonds, mutual funds, or publicly traded stocks

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

 

No Yes ..................

Institution or issuer name: _________________________________________________________________________________________

$__________________

_________________________________________________________________________________________

$__________________

_________________________________________________________________________________________

$__________________

19. Non-publicly traded stock and interests in incorporated and unincorporated businesses, including an interest in

an LLC, partnership, and joint venture

 No  Yes. Give specific information about them. ........................

Name of entity:

% of ownership:

_____________________________________________________________________

___________%

$__________________

_____________________________________________________________________

___________%

$__________________

_____________________________________________________________________

___________%

$__________________

Page 8

20. Government and corporate bonds and 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.

 No  Yes. Give specific information about them. ......................

Issuer name: ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________

$__________________ $__________________ $__________________

21. Retirement or pension accounts

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

 

No Yes. List each account separately. . Type of account:

Institution name:

401(k) or similar plan:

___________________________________________________________________

$__________________

Pension plan:

___________________________________________________________________

$__________________

IRA:

___________________________________________________________________

$__________________

Retirement account:

___________________________________________________________________

$__________________

Keogh:

___________________________________________________________________

$__________________

Additional account:

___________________________________________________________________

$__________________

Additional account:

___________________________________________________________________

$__________________

22. Security deposits and 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

 

No Yes ...........................

Institution name or individual: Electric:

______________________________________________________________________

$___________________

Gas:

______________________________________________________________________

$___________________

Heating oil:

______________________________________________________________________

$___________________

Security deposit on rental unit: _____________________________________________________________

$___________________

Prepaid rent:

______________________________________________________________________

$___________________

Telephone:

______________________________________________________________________

$___________________

Water:

______________________________________________________________________

$___________________

Rented furniture:

______________________________________________________________________

Other:

______________________________________________________________________

$___________________ $___________________

23. Annuities (A contract for a periodic payment of money to you, either for life or for a number of years)

 

No Yes ...........................

Issuer name and description: _______________________________________________________________________________________

$__________________

_______________________________________________________________________________________

$__________________

_______________________________________________________________________________________

$__________________

Page 9

24. Interests in an education IRA, in an account in a qualified ABLE program, or under a qualified state tuition program.

26 U.S.C. §§ 530(b)(1), 529A(b), and 529(b)(1).

 

No Yes .....................................

Institution name and description. Separately file the records of any interests.11 U.S.C. § 521(c): ____________________________________________________________________________________

$_________________

____________________________________________________________________________________

$_________________

____________________________________________________________________________________

$_________________

25. Trusts, equitable or future interests in property (other than anything listed in line 1), and rights or powers

exercisable for your benefit

 

No Yes. Give specific information about them. ..

$__________________

26. Patents, copyrights, trademarks, trade secrets, and other intellectual property

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

 

No Yes. Give specific information about them. ..

$__________________

27. Licenses, franchises, and other general intangibles

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

 

No Yes. Give specific information about them. ..

$__________________

Money or property owed to you?

Current value of the portion you own? Do not deduct secured claims or exemptions.

28. Tax refunds owed to you

 

No Yes. Give specific information about them, including whether you already filed the returns and the tax years. ......................

Federal:

$_________________

State:

$_________________

Local:

$_________________

29. Family support

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

 

No Yes. Give specific information. ............. Alimony:

$________________

Maintenance:

$________________

Support:

$________________

Divorce settlement:

$________________

Property settlement:

$________________

30. Other amounts someone owes you

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

 

No Yes. Give specific information. ............... $______________________

Page 10

31. Interests in insurance policies

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

 

No Yes. Name the insurance company Company name: of each policy and list its value. ...

Beneficiary:

Surrender or refund value:

___________________________________________ ____________________________

$__________________

___________________________________________ ____________________________

$__________________

___________________________________________ ____________________________

$__________________

32. Any interest in property that is due you from someone who has died

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.

 

No Yes. Give specific information. ............. $_____________________

33. Claims against third parties, whether or not you have filed a lawsuit or made a demand for payment

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

 

No Yes. Describe each claim. ..................... $______________________

34. Other contingent and unliquidated claims of every nature, including counterclaims of the debtor and rights

to set off claims

 

No Yes. Describe each claim. ..................... $_____________________

35. Any financial assets you did not already list

 

No Yes. Give specific information. ...........

$_____________________

36. Add the dollar value of all of your entries from Part 4, including any entries for pages you have attached

for Part 4. Write that number here ........................................................................................................................................................ 

Part 5:

$_____________________

Describe Any Business-Related Property You Own or Have an Interest In. List any real estate in Part 1.

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

 

No. Go to Part 6. Yes. Go to line 38. Current value of the portion you own? Do not deduct secured claims or exemptions.

38. Accounts receivable or commissions you already earned

 

No Yes. Describe ....... $_____________________

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

 

No Yes. Describe .......

$_____________________

Page 11

40. Machinery, fixtures, equipment, supplies you use in business, and tools of your trade

 

No Yes. Describe .......

$_____________________

41. Inventory

 

No Yes. Describe .......

$_____________________

42. Interests in partnerships or joint ventures

 

No Yes. Describe ....... Name of entity:

% of ownership:

______________________________________________________________________

________%

$_____________________

______________________________________________________________________

________%

$_____________________

______________________________________________________________________

________%

$_____________________

43. Customer lists, mailing lists, or other compilations

 

No Yes. Do your lists include personally identifiable information (as defined in 11 U.S.C. § 101(41A))?

 

No Yes. Describe......... $____________________

44. Any business-related property you did not already list

 

No Yes. Give specific ______________________________________________________________________________________ information .........

$____________________

______________________________________________________________________________________

$____________________

______________________________________________________________________________________

$____________________

______________________________________________________________________________________

$____________________

______________________________________________________________________________________

$____________________

______________________________________________________________________________________

$____________________

45. Add the dollar value of all of your entries from Part 5, including any entries for pages you have attached

for Part 5. Write that number here ........................................................................................................................................................ 

Part 6:

$____________________

Describe Any Farm- and Commercial Fishing-Related Property You Own or Have an Interest In. If you own or have an interest in farmland, list it in Part 1.

46. Do you own or have any legal or equitable interest in any farm- or commercial fishing-related property?

 

No. Go to Part 7. Yes. Go to line 47. Current value of the portion you own? Do not deduct secured claims or exemptions.

47. Farm animals

Examples: Livestock, poultry, farm-raised fish

 

No Yes ........................... $___________________

Page 12

48. Crops—either growing or harvested

 

No Yes. Give specific information. ............

$___________________

49. Farm and fishing equipment, implements, machinery, fixtures, and tools of trade

 

No Yes ........................... $___________________

50. Farm and fishing supplies, chemicals, and feed

 

No Yes ........................... $___________________

51. Any farm- and commercial fishing-related property you did not already list

 

No Yes. Give specific information. ............

$___________________

52. Add the dollar value of all of your entries from Part 6, including any entries for pages you have attached

for Part 6. Write that number here ........................................................................................................................................................ 

Part 7:

$___________________

Describe All Property You Own or Have an Interest in That You Did Not List Above

53. Do you have other property of any kind you did not already list? Examples: Season tickets, country club membership

 

No $________________

Yes. Give specific information. ............

$________________ $________________

54. Add the dollar value of all of your entries from Part 7. Write that number here ................................................................... 

Part 8:

$________________

List the Totals of Each Part of this Form

55. Part 1: Total real estate, line 2 .................................................................................................................................................................... 56. Part 2: Total vehicles, line 5

$________________

57. Part 3: Total personal and household items, line 15

$________________

58. Part 4: Total financial assets, line 36

$________________

59. Part 5: Total business-related property, line 45

$________________

60. Part 6: Total farm- and fishing-related property, line 52

$________________

61. Part 7: Total other property not listed, line 54 62. Total personal property. Add lines 56 through 61. ...................

$________________

+ $________________ $________________



63. Total of all property on Schedule A/B. Add line 55 + line 62. .......................................................................................

Page 13

+ $_________________ $_________________

SCHEDULE D - CREDITORS HOLDING SECURED CLAIMS State the name, mailing address, including zip code, and last four digits of any account number of all entities holding claims secured by property of the debtor as of the date of filing of the petition. The complete account number of any account the debtor has with the creditor is useful to the trustee and the creditor and may be provided if the debtor chooses to do so. List creditors holding all types of secured interests such as judgment liens, garnishments, statutory liens, mortgages, deeds of trust, and other security interests. List creditors in alphabetical order to the extent practicable. If a minor child is the creditor, state the child's initials and the name and address of the child's parent or guardian, such as "A.B., a minor child, by John Doe, guardian." Do not disclose the child's name. See, 11 U.S.C. §112 and Fed. R. Bankr. P. 1007(m). If all secured creditors will not fit on this page, use the continuation sheet provided. If any entity other than a spouse in a joint case may be jointly liable on a claim, place an “X” in the column labeled “Codebtor,” include the entity on the appropriate schedule of creditors, and complete Schedule H – Codebtors. If a joint petition is filed, state whether the husband, wife, both of them, or the marital community may be liable on each claim by placing an “H,” “W,” “J,” or “C” in the column labeled “Husband, Wife, Joint, or Community.” If the claim is contingent, place an “X” in the column labeled “Contingent.” If the claim is unliquidated, place an “X” in the column labeled “Unliquidated.” If the claim is disputed, place an “X” in the column labeled “Disputed.” (You may need to place an “X” in more than one of these three columns.) Total the columns labeled “Amount of Claim Without Deducting Value of Collateral” and “Unsecured Portion, if Any” in the boxes labeled “Total(s)” on the last sheet of the completed schedule. Report the total from the column labeled “Amount of Claim Without Deducting Value of Collateral” also on the Summary of Schedules and, if the debtor is an individual with primarily consumer debts, report the total from the column labeled “Unsecured Portion, if Any” on the Statistical Summary of Certain Liabilities and Related Data.

DISPUTED

UNLIQUIDATED

ACCOUNT NO.

DATE CLAIM WAS INCURRED, NATURE OF LIEN , AND DESCRIPTION AND VALUE OF PROPERTY SUBJECT TO LIEN

CONTINGENT

CREDITOR’S NAME AND MAILING ADDRESS INCLUDING ZIP CODE AND AN ACCOUNT NUMBER (See Instructions Above.)

HUSBAND, WIFE, JOINT, OR COMMUNITY

Check this box if debtor has no creditors holding secured claims to report on this Schedule D.

CODEBTOR

□

AMOUNT OF CLAIM WITHOUT DEDUCTING VALUE OF COLLATERAL

UNSECURED PORTION, IF ANY

VALUE $ ACCOUNT NO.

ACCOUNT NO.

____continuation sheets attached

VALUE $

VALUE $ Subtotal ► (Total of this page)

$

$

Total ► (Use only on last page)

$

$

(Report also on Summary of Schedules.)

(If applicable, report also on Statistical Summary of Certain Liabilities and Related Data.)

Page 14

B6E (Official Form 6E) (04/13)

In re

,

Case No.

Debtor

(if known)

SCHEDULE E - CREDITORS HOLDING UNSECURED PRIORITY CLAIMS A complete list of claims entitled to priority, listed separately by type of priority, is to be set forth on the sheets provided. Only holders of unsecured claims entitled to priority should be listed in this schedule. In the boxes provided on the attached sheets, state the name, mailing address, including zip code, and last four digits of the account number, if any, of all entities holding priority claims against the debtor or the property of the debtor, as of the date of the filing of the petition. Use a separate continuation sheet for each type of priority and label each with the type of priority. The complete account number of any account the debtor has with the creditor is useful to the trustee and the creditor and may be provided if the debtor chooses to do so. If a minor child is a creditor, state the child's initials and the name and address of the child's parent or guardian, such as "A.B., a minor child, by John Doe, guardian." Do not disclose the child's name. See, 11 U.S.C. §112 and Fed. R. Bankr. P. 1007(m). If any entity other than a spouse in a joint case may be jointly liable on a claim, place an "X" in the column labeled "Codebtor," include the entity on the appropriate schedule of creditors, and complete Schedule H-Codebtors. If a joint petition is filed, state whether the husband, wife, both of them, or the marital community may be liable on each claim by placing an "H," "W," "J," or "C" in the column labeled "Husband, Wife, Joint, or Community." If the claim is contingent, place an "X" in the column labeled "Contingent." If the claim is unliquidated, place an "X" in the column labeled "Unliquidated." If the claim is disputed, place an "X" in the column labeled "Disputed." (You may need to place an "X" in more than one of these three columns.) Report the total of claims listed on each sheet in the box labeled "Subtotals" on each sheet. Report the total of all claims listed on this Schedule E in the box labeled “Total” on the last sheet of the completed schedule. Report this total also on the Summary of Schedules. Report the total of amounts entitled to priority listed on each sheet in the box labeled "Subtotals" on each sheet. Report the total of all amounts entitled to priority listed on this Schedule E in the box labeled “Totals” on the last sheet of the completed schedule. Individual debtors with primarily consumer debts report this total also on the Statistical Summary of Certain Liabilities and Related Data. Report the total of amounts not entitled to priority listed on each sheet in the box labeled “Subtotals” on each sheet. Report the total of all amounts not entitled to priority listed on this Schedule E in the box labeled “Totals” on the last sheet of the completed schedule. Individual debtors with primarily consumer debts report this total also on the Statistical Summary of Certain Liabilities and Related Data. Check this box if debtor has no creditors holding unsecured priority claims to report on this Schedule E.

TYPES OF PRIORITY CLAIMS (Check the appropriate box(es) below if claims in that category are listed on the attached sheets.) Domestic Support Obligations Claims for domestic support that are owed to or recoverable by a spouse, former spouse, or child of the debtor, or the parent, legal guardian, or responsible relative of such a child, or a governmental unit to whom such a domestic support claim has been assigned to the extent provided in 11 U.S.C. § 507(a)(1). Extensions of credit in an involuntary case Claims arising in the ordinary course of the debtor's business or financial affairs after the commencement of the case but before the earlier of the appointment of a trustee or the order for relief. 11 U.S.C. § 507(a)(3). Wages, salaries, and commissions Wages, salaries, and commissions, including vacation, severance, and sick leave pay owing to employees and commissions owing to qualifying independent sales representatives up to $12,475* per person earned within 180 days immediately preceding the filing of the original petition, or the cessation of business, whichever occurred first, to the extent provided in 11 U.S.C. § 507(a)(4). Contributions to employee benefit plans Money owed to employee benefit plans for services rendered within 180 days immediately preceding the filing of the original petition, or the cessation of business, whichever occurred first, to the extent provided in 11 U.S.C. § 507(a)(5).

* Amount subject to adjustment on 4/01/16, and every three years thereafter with respect to cases commenced on or after the date of adjustment.

Page 15

B6E (Official Form 6E) (04/13) – Cont.

In re

,

Case No.

Debtor

(if known)

Certain farmers and fishermen Claims of certain farmers and fishermen, up to $6,150* per farmer or fisherman, against the debtor, as provided in 11 U.S.C. § 507(a)(6).

Deposits by individuals Claims of individuals up to $2,775* for deposits for the purchase, lease, or rental of property or services for personal, family, or household use, that were not delivered or provided. 11 U.S.C. § 507(a)(7).

Taxes and Certain Other Debts Owed to Governmental Units Taxes, customs duties, and penalties owing to federal, state, and local governmental units as set forth in 11 U.S.C. § 507(a)(8).

Commitments to Maintain the Capital of an Insured Depository Institution Claims based on commitments to the FDIC, RTC, Director of the Office of Thrift Supervision, Comptroller of the Currency, or Board of Governors of the Federal Reserve System, or their predecessors or successors, to maintain the capital of an insured depository institution. 11 U.S.C. § 507 (a)(9).

Claims for Death or Personal Injury While Debtor Was Intoxicated Claims for death or personal injury resulting from the operation of a motor vehicle or vessel while the debtor was intoxicated from using alcohol, a drug, or another substance. 11 U.S.C. § 507(a)(10).

* Amounts are subject to adjustment on 4/01/16, and every three years thereafter with respect to cases commenced on or after the date of adjustment.

____ continuation sheets attached

Page 16

B6E (Official Form 6E) (04/13) – Cont.

In re __________________________________________,

Case No. _________________________________

Debtor

(if known)

SCHEDULE E - CREDITORS HOLDING UNSECURED PRIORITY CLAIMS (Continuation Sheet)

AMOUNT OF CLAIM

DISPUTED

UNLIQUIDATED

DATE CLAIM WAS INCURRED AND CONSIDERATION FOR CLAIM

CONTINGENT

HUSBAND, WIFE, JOINT, OR COMMUNITY

CREDITOR’S NAME, MAILING ADDRESS INCLUDING ZIP CODE, AND ACCOUNT NUMBER (See instructions above.)

CODEBTOR

Type of Priority for Claims Listed on This Sheet

AMOUNT ENTITLED TO PRIORITY

AMOUNT NOT ENTITLED TO PRIORITY, IF ANY

Account No.

Account No.

Account No.

Account No.

Sheet no. ___ of ___ continuation sheets attached to Schedule of Creditors Holding Priority Claims

Subtotals' (Totals of this page)

$

Total' (Use only on last page of the completed Schedule E. Report also on the Summary of Schedules.)

$

Totals' (Use only on last page of the completed Schedule E. If applicable, report also on the Statistical Summary of Certain Liabilities and Related Data.)

Page 17

$

$

$

SCHEDULE F - CREDITORS HOLDING UNSECURED NONPRIORITY CLAIMS State the name, mailing address, including zip code, and last four digits of any account number, of all entities holding unsecured claims without priority against the debtor or the property of the debtor, as of the date of filing of the petition. The complete account number of any account the debtor has with the creditor is useful to the trustee and the creditor and may be provided if the debtor chooses to do so. If a minor child is a creditor, state the child's initials and the name and address of the child's parent or guardian, such as "A.B., a minor child, by John Doe, guardian." Do not disclose the child's name. See, 11 U.S.C. §112 and Fed.R. Bankr. P. 1007(m). Do not include claims listed in Schedules D and E. If all creditors will not fit on this page, use the continuation sheet provided. If any entity other than a spouse in a joint case may be jointly liable on a claim, place an “X” in the column labeled “Codebtor,” include the entity on the appropriate schedule of creditors, and complete Schedule H - Codebtors. If a joint petition is filed, state whether the husband, wife, both of them, or the marital community may be liable on each claim by placing an “H,” “W,” “J,” or “C” in the column labeled “Husband, Wife, Joint, or Community.” If the claim is contingent, place an “X” in the column labeled “Contingent.” If the claim is unliquidated, place an “X” in the column labeled “Unliquidated.” If the claim is disputed, place an “X” in the column labeled “Disputed.” (You may need to place an “X” in more than one of these three columns.) Report the total of all claims listed on this schedule in the box labeled “Total” on the last sheet of the completed schedule. Report this total also on the Summary of Schedules and, if the debtor is an individual with primarily consumer debts, report this total also on the Statistical Summary of Certain Liabilities and Related Data.

Creditor’s name

Mailing Address, including zip code

(Ex. Citibank)

(ex. 123 Main St., Anywhere, CA 90000)

Date of claim

Amount of claim

Husband, Wife Joint, Community (married filers only)

_____________________

____________________________

_____________________

____________________________

Account #

____________________________

___________________________

H/W/J/C

__/__/____

$ ______

MM/DD/YY

_____________________

____________________________

_____________________

____________________________

Account #

____________________________

___________________________

H/W/J/C

__/__/____

$ ______

MM/DD/YY

_____________________

____________________________

_____________________

____________________________

Account #

____________________________

___________________________

H/W/J/C

__/__/____

$ ______

MM/DD/YY

_____________________

____________________________

_____________________

____________________________

Account #

____________________________

___________________________

H/W/J/C

__/__/____ MM/DD/YY

Page 18

$ ______

_____________________

____________________________

_____________________

____________________________

Account #

____________________________

___________________________

__/__/____

$ ______

MM/DD/YY

_____________________

____________________________

_____________________

____________________________

Account #

____________________________

___________________________

H/W/J/C

__/__/____

$ ______

MM/DD/YY

_____________________

____________________________

_____________________

____________________________

Account #

____________________________

___________________________

H/W/J/C

__/__/____

$ ______

MM/DD/YY

_____________________

____________________________

_____________________

____________________________

Account #

____________________________

___________________________

H/W/J/C

__/__/____

$ ______

MM/DD/YY

_____________________

____________________________

_____________________

____________________________

Account #

____________________________

___________________________

H/W/J/C

__/__/____

$ ______

MM/DD/YY

_____________________

____________________________

_____________________

____________________________

Account #

____________________________

___________________________

H/W/J/C

__/__/____

$ ______

MM/DD/YY

_____________________

____________________________

_____________________

____________________________

Account #

____________________________

___________________________

H/W/J/C

H/W/J/C

__/__/____

$ ______

MM/DD/YY

If you have more entries, please print out additional copies of this page Page 19

SCHEDULE G – EXECUTORY CONTRACTS AND UNESPIRED LEASES Describe all executory contracts of any nature and all unexpired leases of real or personal property. Include any timeshare interests. State nature of debtor’s interest in contract, i.e., “Purchaser,” “Agent,” etc. State whether debtor is the lessor or lessee of a lease. Provide the names and complete mailing addresses of all other parties to each lease or contract described. If a minor child is a party to one of the leases or contracts, state the child's initials and the name and address of the child's parentor guardian, such as "A.B., a minor child, by John Doe, guardian." Do not disclose the child's name. See, 11 U.S.C. §112 andFed. R. Bankr. P. 1007(m).

 Check this box if debtor has no executory contracts or unexpired leases. Name and full mailing address of other parties to lease or contract

Description of contract or lease and nature of debtor’s interest. State whether lease is for nonresidential real property. State contract number or any Government contract.

Page 20

Will lease be assumed pursuant to 11 U.S.C. §365 (p)(2)?

 YES

 NO

 YES

 NO

 YES

 NO

 YES

 NO

 YES

 NO

 YES

 NO

B 6H (Official Form 6H) (12/07)

In re

Debtor

,

Case No.

(if known)

SCHEDULE H - CODEBTORS Provide the information requested concerning any person or entity, other than a spouse in a joint case, that is also liable on any debts listed by the debtor in the schedules of creditors. Include all guarantors and co-signers. If the debtor resides or resided in a community property state, commonwealth, or territory (including Alaska, Arizona, California, Idaho, Louisiana, Nevada, New Mexico, Puerto Rico, Texas, Washington, or Wisconsin) within the eight-year period immediately preceding the commencement of the case, identify the name of the debtor’s spouse and of any former spouse who resides or resided with the debtor in the community property state, commonwealth, or territory. Include all names used by the nondebtor spouse during the eight years immediately preceding the commencement of this case. If a minor child is a codebtor or a creditor, state the child's initials and the name and address of the child's parent or guardian, such as "A.B., a minor child, by John Doe, guardian." Do not disclose the child's name. See, 11 U.S.C. §112 and Fed. R. Bankr. P. 1007(m). Check this box if debtor has no codebtors. NAME AND ADDRESS OF CODEBTOR

NAME AND ADDRESS OF CREDITOR

Page 21

Page 22

Page 23

Page 24

Page 25

Page 26

Statement of Financial Affairs Be as complete and accurate as possible. If two married people are filing together, both are equally responsible for supplying correct information. If more space is needed, attach a separate sheet to this form. On the top of any additional pages, write your name and case number (if known). Answer every question. Part 1:

Give Details About Your Marital Status and Where You Lived Before

1. What is your current marital status?

 Married  Not married 2. During the last 3 years, have you lived anywhere other than where you live now?

 

No Yes. List all of the places you lived in the last 3 years. Do not include where you live now. Debtor 1:

Dates Debtor 1 lived there

Debtor 2:

 Same as Debtor 1 __________________________________________ Number Street

From

________

To

________

__________________________________________ City State ZIP Code

___________________________________________ City State ZIP Code

 Same as Debtor 1 ________

To

________

Same as Debtor 1

From ________ To

___________________________________________

From



___________________________________________ Number Street

__________________________________________

__________________________________________ Number Street

Dates Debtor 2 lived there

___________________________________________ Number Street



Same as Debtor 1

From ________ To

__________________________________________

___________________________________________

__________________________________________ City State ZIP Code

___________________________________________ City State ZIP Code

________

________

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

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

 

No Yes. Make sure you fill out Schedule H: Your Codebtors (Official Form 106H).

Part 2: Explain the Sources of Your Income

Page 27

Part 2: Explain the Sources of Your Income 4. Did you have any income from employment or from operating a business during this year or the two previous calendar years?

Fill in the total amount of income you received from all jobs and all businesses, including part-time activities. If you are filing a joint case and you have income that you receive together, list it only once under Debtor 1.



 

No Yes. Fill in the details. Debtor 1

Debtor 2

Sources of income Check all that apply.

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

 

For last calendar year:



(January 1 to December 31, _________)



YYYY

For the calendar year before that:



(January 1 to December 31, _________)



YYYY

Gross income (before deductions and exclusions)

Wages, commissions, bonuses, tips

$________________

 $________________

Operating a business

Wages, commissions, bonuses, tips Operating a business

 

Operating a business Wages, commissions, bonuses, tips

Sources of income Check all that apply.

 

$________________



Wages, commissions, bonuses, tips

Gross income (before deductions and exclusions)

$________________

Operating a business Wages, commissions, bonuses, tips

$________________

Operating a business

Wages, commissions, bonuses, tips Operating a business

$________________

5. Did you receive any other income during this year or the two previous calendar years?

Include income regardless of whether that income is taxable. Examples of other income are 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. If you are filing a joint case and you have income that you received together, list it only once under Debtor 1. List each source and the gross income from each source separately. Do not include income that you listed in line 4.

 

No Yes. Fill in the details. Debtor 1

Debtor 2

Sources of income Describe below.

Gross income from each source (before deductions and exclusions)

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

Sources of income Describe below.

Gross income from each source (before deductions and exclusions)

$_________________ _____________________ $_________________ $_________________ _____________________ $_________________ $_________________ _____________________ $_________________

__________________

$_________________ _____________________ $_________________

__________________

$_________________ _____________________ $_________________

__________________

$_________________ _____________________ $_________________

For the calendar year before that:

__________________

$_________________ _____________________ $_________________

(January 1 to December 31, ______)

__________________

$_________________ _____________________ $_________________

__________________

$_________________ _____________________ $_________________

For last calendar year: (January 1 to December 31, ______) YYYY

YYYY

Page 28

Part 3:

List Certain Payments You Made Before You Filed for Bankruptcy

6. Are either Debtor 1’s or Debtor 2’s debts primarily consumer debts?



No. Neither Debtor 1 nor Debtor 2 has primarily consumer debts. Consumer debts are defined in 11 U.S.C. § 101(8) as “incurred by an individual primarily for a personal, family, or household purpose.” During the 90 days before you filed for bankruptcy, did you pay any creditor a total of $6,225* or more?

 

No. Go to line 7. Yes. List below each creditor to whom you paid a total of $6,225* or more in one or more payments and the total amount you paid that creditor. Do not include payments for domestic support obligations, such as child support and alimony. Also, do not include payments to an attorney for this bankruptcy case.

* Subject to adjustment on 4/01/16 and every 3 years after that for cases filed on or after the date of adjustment.



Yes. Debtor 1 or Debtor 2 or both have primarily consumer debts. During the 90 days before you filed for bankruptcy, did you pay any creditor a total of $600 or more?

 

No. Go to line 7. Yes. List below each creditor to whom you paid a total of $600 or more and the total amount you paid that creditor. Do not include payments for domestic support obligations, such as child support and alimony. Also, do not include payments to an attorney for this bankruptcy case. Dates of payment

____________________________________

_________

Total amount paid

Amount you still owe

$_________________ $__________________

 Mortgage  Car  Credit card  Loan repayment  Suppliers or vendors  Other ____________

$_________________ $__________________

 Mortgage  Car  Credit card  Loan repayment  Suppliers or vendors  Other ____________

$_________________ $__________________

 Mortgage  Car  Credit card  Loan repayment  Suppliers or vendors  Other ____________

Creditor’s Name

____________________________________ Number

_________

Street

____________________________________

_________

____________________________________ City

State

ZIP Code

____________________________________

_________

Creditor’s Name

____________________________________ Number

_________

Street

____________________________________

_________

____________________________________ City

State

ZIP Code

____________________________________

_________

Creditor’s Name

____________________________________ Number

_________

Street

____________________________________

_________

____________________________________ City

State

Was this payment for…

ZIP Code

Page 29

7. Within 1 year before you filed for bankruptcy, did you make a payment on a debt you owed anyone who was an insider?

Insiders include your relatives; any general partners; relatives of any general partners; partnerships of which you are a general partner; corporations of which you are an officer, director, person in control, or owner of 20% or more of their voting securities; and any managing agent, including one for a business you operate as a sole proprietor. 11 U.S.C. § 101. Include payments for domestic support obligations, such as child support and alimony.

 

No Yes. List all payments to an insider. Dates of payment ____________________________________________

_________

Total amount paid

Amount you still owe

Reason for this payment

$____________ $____________

Insider’s Name

____________________________________________ Number

_________

Street

____________________________________________

_________

____________________________________________ City

State

ZIP Code

____________________________________________

_________

$____________ $____________

Insider’s Name

____________________________________________ Number

_________

Street

____________________________________________

_________

____________________________________________ City

State

ZIP Code

8. Within 1 year before you filed for bankruptcy, 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.

 

No Yes. List all payments that benefited an insider. Dates of payment ____________________________________________ Insider’s Name

____________________________________________ Number

_________

Total amount paid

Amount you still owe

$____________ $____________

_________

Street

____________________________________________

_________

____________________________________________ City

State

ZIP Code

____________________________________________

_________

$____________ $____________

Insider’s Name

____________________________________________ Number

_________

Street

____________________________________________

_________

____________________________________________ City

State

ZIP Code

Page 30

Reason for this payment Include creditor’s name

Part 4:

Identify Legal Actions, Repossessions, and Foreclosures

9. Within 1 year before you filed for bankruptcy, were you a party in any lawsuit, 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.

 

No Yes. Fill in the details. Nature of the case

Court or agency

Status of the case

________________________________________

Case title_____________________________

Court Name

____________________________________

________________________________________ Number

Case number ________________________

Street

  

Pending On appeal Concluded

________________________________________ City

State

ZIP Code

________________________________________

Case title_____________________________

Court Name

____________________________________

________________________________________ Number

Case number ________________________

Street

  

Pending On appeal Concluded

________________________________________ City

State

ZIP Code

10. Within 1 year before you filed for bankruptcy, was any of your property repossessed, foreclosed, garnished, attached, seized, or levied?

Check all that apply and fill in the details below.

 

No. Go to line 11. Yes. Fill in the information below. Describe the property

_________________________________________

Date

__________

Creditor’s Name

Value of the property

$______________

_________________________________________ Number

Explain what happened

Street

_________________________________________

_________________________________________ City

State

ZIP Code

   

Property was repossessed. Property was foreclosed. Property was garnished. Property was attached, seized, or levied.

Describe the property

__________

_________________________________________ Creditor’s Name

_________________________________________ Number

Street

Explain what happened _________________________________________

_________________________________________ City

State

ZIP Code

Date

   

Property was repossessed. Property was foreclosed. Property was garnished. Property was attached, seized, or levied.

Page 31

Value of the property

$______________

11. Within 90 days before you filed for bankruptcy, 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?

 

No Yes. Fill in the details. Describe the action the creditor took ______________________________________

Date action was taken

Amount

Creditor’s Name

______________________________________ Number

____________ $________________

Street

______________________________________ ______________________________________ City

State

ZIP Code

Last 4 digits of account number: XXXX–___ ___ ___ ___

12. Within 1 year before you filed for bankruptcy, was any of your property in the possession of an assignee for the benefit of

creditors, a court-appointed receiver, a custodian, or another official?

 

No Yes

Part 5:

List Certain Gifts and Contributions

13. Within 2 years before you filed for bankruptcy, did you give any gifts with a total value of more than $600 per person?

 

No Yes. Fill in the details for each gift. Gifts with a total value of more than $600 per person

Describe the gifts

______________________________________

Dates you gave the gifts

Value

_________

$_____________

_________

$_____________

Person to Whom You Gave the Gift

______________________________________ ______________________________________ Number

Street

______________________________________ City

State

Person’s relationship to you

ZIP Code

______________

Gifts with a total value of more than $600 per person

Describe the gifts

______________________________________

Dates you gave the gifts

Value

_________

$_____________

_________

$_____________

Person to Whom You Gave the Gift

______________________________________

______________________________________ Number

Street

______________________________________ City

State

ZIP Code

Person’s relationship to you ______________

Page 32

14. Within 2 years before you filed for bankruptcy, did you give any gifts or contributions with a total value of more than $600 to any charity?

 

No Yes. Fill in the details for each gift or contribution. Gifts or contributions to charities that total more than $600

Describe what you contributed

_____________________________________

Date you contributed

Value

_________

$_____________

_________

$_____________

Charity’s Name

_____________________________________

_____________________________________ Number

Street

_____________________________________ City

State

Part 6:

ZIP Code

List Certain Losses

15. Within 1 year before you filed for bankruptcy or since you filed for bankruptcy, did you lose anything because of theft, fire, other

disaster, or gambling?

 

No Yes. Fill in the details. Describe the property you lost and how the loss occurred

Describe any insurance coverage for the loss Include the amount that insurance has paid. List pending insurance claims on line 33 of Schedule A/B: Property.

Date of your loss

_________

Part 7:

Value of property lost

$_____________

List Certain Payments or Transfers

16. Within 1 year before you filed for bankruptcy, did you or anyone else acting on your behalf pay or transfer any property to anyone

you consulted about seeking bankruptcy or preparing a bankruptcy petition? Include any attorneys, bankruptcy petition preparers, or credit counseling agencies for services required in your bankruptcy.

 

No Yes. Fill in the details. Description and value of any property transferred ___________________________________ Person Who Was Paid

Date payment or transfer was made

Amount of payment

_________

$_____________

_________

$_____________

___________________________________ Number

Street

___________________________________ ___________________________________ City

State

ZIP Code

____________________________________________ Email or website address

___________________________________ Person Who Made the Payment, if Not You

Page 33

Description and value of any property transferred

Date payment or transfer was made

Amount of payment

____________________________________ Person Who Was Paid

_________

$_____________

_________

$_____________

____________________________________ Number

Street

____________________________________ ____________________________________ City

State

ZIP Code

________________________________________________ Email or website address

___________________________________ Person Who Made the Payment, if Not You

17. Within 1 year before you filed for bankruptcy, did you or anyone else acting on 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? Do not include any payment or transfer that you listed on line 16.

 

No Yes. Fill in the details. Description and value of any property transferred ____________________________________

Date payment or transfer was made

Amount of payment

_________

$____________

_________

$____________

Person Who Was Paid

____________________________________ Number

Street

____________________________________ ____________________________________ City

State

ZIP Code

18. Within 2 years before you filed for bankruptcy, did you sell, trade, or otherwise transfer any property to anyone, other than property

transferred in the ordinary course of your 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.

 

No Yes. Fill in the details. Description and value of property transferred

Describe any property or payments received or debts paid in exchange

Date transfer was made

___________________________________ Person Who Received Transfer

_________

___________________________________ Number

Street

___________________________________ ___________________________________ City

State

ZIP Code

Person’s relationship to you _____________ ___________________________________ Person Who Received Transfer

_________

___________________________________ Number

Street

___________________________________ ___________________________________ City

State

ZIP Code

Person’s relationship to you _____________

Page 34

19. Within 10 years before you filed for bankruptcy, 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.)

 

No Yes. Fill in the details. Description and value of the property transferred

Date transfer was made

_________

Name of trust __________________________

______________________________________

Part 8: List Certain Financial Accounts, Instruments, Safe Deposit Boxes, and Storage Units 20. Within 1 year before you filed for bankruptcy, 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 houses, pension funds, cooperatives, associations, and other financial institutions.

 

No Yes. Fill in the details. Last 4 digits of account number

Type of account or instrument

Date account was closed, sold, moved, or transferred

Last balance before closing or transfer

_________

$___________

_________

$___________

____________________________________ Name of Financial Institution

XXXX–___ ___ ___ ___

____________________________________ Number

Street

____________________________________ ____________________________________ City

State

ZIP Code

____________________________________

XXXX–___ ___ ___ ___

Name of Financial Institution

____________________________________ Number

Street

____________________________________ ____________________________________ City

State

 Checking  Savings  Money market  Brokerage  Other__________  Checking  Savings  Money market  Brokerage  Other__________

ZIP Code

21. Do you now have, or did you have within 1 year before you filed for bankruptcy, any safe deposit box or other depository for

securities, cash, or other valuables?

 

No Yes. Fill in the details. Who else had access to it?

____________________________________ Name of Financial Institution

Name

____________________________________ Number

Street

_______________________________________ Number

____________________________________ ____________________________________ City

_______________________________________

State

Street

_______________________________________ City

State

ZIP Code

ZIP Code

Page 35

Describe the contents

Do you still have it?

  

No Yes

22. Have you stored property in a storage unit or place other than your home within 1 year before you filed for bankruptcy?

 

No Yes. Fill in the details. Who else has or had access to it?

Describe the contents

___________________________________

_______________________________________

Name of Storage Facility

Name

___________________________________

_______________________________________

Number

Number

Street

___________________________________

Do you still have it?

 No  Yes 

Street

_______________________________________ City State ZIP Code

___________________________________ City

Part 9:

State

ZIP Code

Identify Property You Hold or Control for Someone Else

23. Do you hold or control any property that someone else owns? Include any property you borrowed from, are storing for,

or hold in trust for someone.

 

No Yes. Fill in the details. Where is the property?

Describe the property

Value

___________________________________

$__________

Owner’s Name

___________________________________ Number

Street

___________________________________ ___________________________________ City

Part 10:

State

ZIP Code

_________________________________________ Number

Street

_________________________________________ _________________________________________ City

State

ZIP Code

Give Details About Environmental Information

For the purpose of Part 10, the following definitions apply:  Environmental law means any federal, state, or local statute or regulation concerning pollution, contamination, releases of

hazardous or toxic substances, wastes, or material into the air, land, soil, surface water, groundwater, or other medium, including statutes or regulations controlling the cleanup of these substances, wastes, or material.  Site means any location, facility, or property as defined under any environmental law, whether you now own, operate, or

utilize it or used to own, operate, or utilize it, including disposal sites.  Hazardous material means anything an environmental law defines as a hazardous waste, hazardous substance, toxic

substance, hazardous material, pollutant, contaminant, or similar term. Report all notices, releases, and proceedings that you know about, regardless of when they occurred. 24. Has any governmental unit notified you that you may be liable or potentially liable under or in violation of an environmental law?

 

No Yes. Fill in the details. Governmental unit

Environmental law, if you know it

____________________________________

_______________________________

Name of site

Governmental unit

____________________________________

_______________________________

Number

Number

Street

____________________________________

Street

_______________________________ City

State

ZIP Code

____________________________________ City

State

ZIP Code

Page 36

Date of notice

_________

25. Have you notified any governmental unit of any release of hazardous material?

 

No Yes. Fill in the details. Governmental unit

Environmental law, if you know it

Date of notice

____________________________________ _______________________________ Name of site

_________

Governmental unit

____________________________________ _______________________________ Number

Street

Number

Street

____________________________________ _______________________________ City

State

ZIP Code

____________________________________ City

State

ZIP Code

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

 

No Yes. Fill in the details. Court or agency Case title______________________________

Status of the case

Nature of the case

 Pending  On appeal  Concluded

________________________________ Court Name

______________________________________

________________________________ Number

______________________________________ Case number

Part 11:

Street

________________________________ City

State



ZIP Code

Give Details About Your Business or Connections to Any Business

27. Within 4 years before you filed for bankruptcy, did you own a business or have any of the following connections to any business?

      

A sole proprietor or self-employed in a trade, profession, or other activity, either full-time or part-time A member of a limited liability company (LLC) or limited liability partnership (LLP) A partner in a partnership An officer, director, or managing executive of a corporation An owner of at least 5% of the voting or equity securities of a corporation

No. None of the above applies. Go to Part 12. Yes. Check all that apply above and fill in the details below for each business. Describe the nature of the business ____________________________________

Do not include Social Security number or ITIN.

Business Name

EIN: ___ ___ – ___ ___ ___ ___ ___ ___ ___

____________________________________ Number

Employer Identification number

Street

Name of accountant or bookkeeper

Dates business existed

____________________________________

From

____________________________________ City

State

Describe the nature of the business ____________________________________

Employer Identification number Do not include Social Security number or ITIN.

Business Name

EIN: ___ ___ – ___ ___ ___ ___ ___ ___ ___

____________________________________ Number

_______ To _______

ZIP Code

Street

Name of accountant or bookkeeper

Dates business existed

____________________________________

From

____________________________________ City

State

ZIP Code

Page 37

_______ To _______

Describe the nature of the business

Employer Identification number Do not include Social Security number or ITIN.

____________________________________ Business Name

EIN: ___ ___ – ___ ___ ___ ___ ___ ___ ___ ____________________________________ Number

Street

Name of accountant or bookkeeper

Dates business existed

____________________________________

From

____________________________________ City

State

_______ To _______

ZIP Code

28. Within 2 years before you filed for bankruptcy, did you give a financial statement to anyone about your business? Include all financial

institutions, creditors, or other parties.

 

No Yes. Fill in the details below. Date issued

____________________________________ Name

____________ MM / DD / YYYY

____________________________________ Number

Street

____________________________________ ____________________________________ City

State

ZIP Code

Page 38

Payment Advices Cover Sheet _ Under 11 U.S.C. § 521 (a)(1)(B)(iv) Debtor(s) declare(s) under penalty of perjury that the following is true and correct (check one): Debtor Joint Debtor





I have not been employed by any employer within the 60 days before the date of the filing of the petition





I was employed by an employer within the 60 days before the date I filed my bankruptcy petition, but I have not received payment advices or other evidence of payment because __________________________________________________





I have received payment advices or other evidence of payment within 60 days before the date I filed my bankruptcy petition from any employer, and they are attached.

===///===///===///===///===///===///===///===///===///===///===///===///===///===///===///===///===///===

Individual Debtor’s Statement of Intention _ Debts secured by property of the estate Property No. 1 Creditor’s Name:

Describe Property Securing Debt:

Property will be (check one):  Surrender  Retained

Property is (check one):  Claimed as exempt

If retaining the property, I intend to (check at least 1)

 NOT claimed as exempt

Property No. 2 Creditor’s Name:

Redeem the property Reaffirm the debt Other. Explain ___________________________________________ (ex., avoid lien using 11 U.S.C. § 522 (f))

Describe Property Securing Debt:

Property will be (check one):  Surrender  Retained

Property is (check one):  Claimed as exempt

  

If retaining the property, I intend to (check at least 1)

 NOT claimed as exempt

  

Redeem the property Reaffirm the debt Other. Explain ___________________________________________ (ex., avoid lien using 11 U.S.C. § 522 (f))

Page 39