I M P O R T A N T

Instructions For Filling Out Client Intake Forms

Your Assets

Everything you have in your possession, from the coffee pot to the house you live in (and everything in between) is an asset. Even if you still owe money to a creditor, the asset you are paying for is still in your possession and its value must be disclosed when you are filing bankruptcy. Your attorney may be able to help you estimate the

value of some property, but in most cases, values can be obtained by you from current mortgage statements, receipts and even bank records.

VERY IMPORTANT

The extra time you spend in providing detailed answers to the questions on these Client Intake Forms will prevent your case from being delayed. If you do not provide the answers, we will need to speak with you at a

later time to obtain the information anyway. So please take the time now and do not allow

your case to be delayed over a few unanswered questions.

Please provide COMPLETE addresses

Providing the complete names and addresses for every debt you owe (as well as the company collecting for this debt [if applicable]) is extremely important.  Without this crucial information, the company you owe money to may not be properly notified by the court and the debt may not be eligible for discharge. Additionally, in some instances, it can even be considered “fraud” not

to provide complete mailing addresses for all creditors because it denies a creditor the right to file a Proof of Claim or Motion for Relief from Stay in a timely manner and could even delay the discharge of your bankruptcy case.

What if you don’t know the address of the company you owe money to?

If you or your attorney requested a credit report before filling out these Client Intake Forms, the

credit report may or may not contain all the addresses you need to properly complete the debt sheets. If you are required to obtain your own credit report you may want to try True Credit at http://www.truecredit.com.  This 3-in-1 report contains addresses and other detailed informa- tion not provided in other credit reports.

However to help you in locating addresses for creditors, the best place to start is to call the toll- free national information line at 1-800-555-1212 and see if a toll-free number is listed under the company’s name. If not, you may need to look in your phone directory or do an online search from Google at http://www.google.com. which we found to be the fasted method of locating current name and address information for companies.

Listing the address of the original company you owe money to as well as the collection agency collecting on the debt is also just as important. By doing this, all parties concerned with the debt are notified by the court and it will greatly aide in deceasing all collection phone calls you may be currently receiving.

What do you do after you have retained an attorney but the credit collectors continue to call you?

Provide the credit collector with the name and telephone number of your bankruptcy attorney. If you have a case number you can provide that also. But do NOT provide any other information whatsoever. Allow your attorney to deal with the creditor. That is what you hired him or her for – to represent you.

Other Tips for Filling out the Debt Sheets:

• Make sure all company names are spelled out. (For example, instead of writing “HSB” for a company name, write out the words “Home Secure Bank” or whatever the case may be.)

• Make sure the street address is readable and any abbreviations are spelled out

• Make sure the city, state, and ZIP are included for all addresses. If the zip code is not known, it can be obtained online: http://www.usps.com.

• Make sure all the information for each creditor is completely filled in. Every piece of this informa- tion is important in preparing a detailed bank- ruptcy petition for you. If you do not know the

exact date you made a debt, or charged on the account, a “year” is sufficient. The “year” can also be within a 2-year time frame. Not providing dates or years will delay the processing of your petition as we must contact you to obtain the information.

• For the “last date charged on this account” line, do not provide the last date you received a statement. We are only interested in the last date you actually made a purchase using this particu- lar charge account.

Means Test Page

To meet the requirement of the changes in the bankruptcy law on October 17, 2005 – you are

now required to pass a Means Test to determine if you are eligible to file a Chapter 7 or 13.

In order to make this determination, the court requires that you provide the amount of income you earned for the last 6 months. Even if your income has drastically increased or decreased recently, the amount of income you received is

still disclosed on the Means Test. This information may or may not be the same for the form named “Income History for You Page” (see below.)

Income History for You

An often overlooked piece of vital information we need on the Income History for You form is your year-to-date income, plus the income you made in the last 2 years. This question appears right below your name on the form page. Your year-to- date income should appear on your recent pay- check stub. However, if you have had more than one employer this year, you will need to provide us with the TOTAL amount of income you made working for ALL employers.

In addition, if you also receive (or have received) another type of income (child support, unemploy- ment, social security, pension, etc.) within the past 2 years, turn the page over (or use an

additional sheet of paper) and provide the income for this year and the last 2 years for each sepa- rate type of income.

Social security income is not considered to be income under the bankruptcy law but your attor- ney still needs to have this information available in your file for reference purposes.

Statement of Affairs Form

Make sure that every box is answered with either a “yes” or “no” on the Statement of Affairs forms within this package.  These pages serve as a written statement concerning your current finan- cial condition. If a box is left unanswered, you will need to provide a written statement that specifi- cally answers this question before your petition can be finalized. Please double-check and make sure you have answered every question on the form pages titled “Statement of Affairs.”

In addition, if any question on the Statement of Affairs forms is answered “yes,” it is extremely important that you fill in all the required informa- tion under the question you checked “yes” to. For instance, some people check “yes” to the item on the Statement of Affairs referring to previous addresses; however, they do not include the city, state and zip code of the address they lived at.

Or, if a car has been repossessed, don’t just call

it a “car” but provide the make, model and year. It is important for you to be as detailed as possible when answering any question “yes.” Also, if you run out of room, turn the paper over and write on the back. The higher level of detail you provide at this initial stage will greatly aide in moving your case along at a fast pace and prevent long delays and additional paperwork later down the road.

Motor Vehicles

Please remember to ALWAYS provide the make, model and year of your motor vehicle.  We must obtain market values of all motor vehicles from the Blue or Black Book for the bankruptcy court. We need all the information on the vehicle,

including the present mileage to obtain the correct market value. Example: 2001 Kia should be

2001 Kia Rio, or 2001 Kia Spectra, or whatever the case may be.  Simply writing the word “car”

does not tell us anything and delays the filing of your bankruptcy petition.

Court Documents

If you have been involved in a court proceeding of any type within the past 12 months, including a foreclosure, wage garnishment, traffic tickets, other fines, lawsuits, judgments for debt collec- tion, etc. — we need to know the following infor- mation, which can be obtained directly from the court pleading you received in the mail:

• Court Heading — (example: John Doe, Plaintiff

-vs- Jane Doe, Defendant)

• Case Number

• Name and address of court where document was filed

• Date document was filed with the court

• Names and complete addresses of any attorneys or parties involved with the case (including the Plaintiff)

• Current status — Has a hearing already taken place? If so, what was the result? If the hearing has not taken place and a decision has not been reached yet, provide the date of the court hearing and let us know if the case is still “pending.”

You may find it easier to simply make a copy of the court document and include it with your Client Intake Forms when you return them to your attorney.

If you no longer have a copy of the court pleading that provides this information, you may be able to go online and get a copy. Go to a search engine like Google at http://www.google.com. Type in a search for your county (example: Franklin County Ohio). If your county is online, you can normally do a simple search by your last name and locate public records that may be helpful in locating the information needed for your bankruptcy petition.

Contracts

Contracts you have may include cell phones, a lease for an automobile or even a contract you entered into with another party to pay back a debt. Be sure to provide the following:

• The date or year the contract began;

• How many months the contract is for;

• How much you pay per month (installment payment);

• If you want to continue paying the contract or not assume the lease; and

• Any details about this contract (lease).

Summary

Thank you for taking the time to read these important instructions before filling out the Client Intake Forms. We understand that filing bank- ruptcy is not something people enjoy doing. In fact, we know this is a stressful time in your life. However, we want to make the experience as easy as possible. The only way we can do this is to obtain all the information that is needed for the attorney to represent you in court.

Thank you for taking the extra steps necessary to help us make this time in your life a little less stressful. And please do not hesitate to call our office if we can assist you in any way. We sin- cerely hope you are happy with our law firm and will want to recommend us to others.

Famous People who filed bankruptcy:

1871 – Phineas Taylor Barnum (Barnum and

Bailey’s Circus)

1872 – Mathew Brady (famous photographer)

1875 – Henry John Heinz (Heinz catsup developer)

1884 – Henry Ford (automobile manufacturer)

1892 – Milton Snavely Hershey (Hershey chocolate)

1894 – Mark Twain (famous writer)

1962 – Mickey Rooney (famous actor)

1988 – Jerry Lee Lewis (famous singer)

1991 – Johnny Unitas (famous quarterback)

1992 – Debbie Reynolds (famouse actress)

1992 – Wayne Newton (famous singer)

1993 – Kim Basinger (famous actress)

1996 – Burt Reynolds (famous actor)

1996 – MC Hammer (famous singer)

1999 – Sherman Hemsley (George Jefferson on the hit 1970s TV show)

2000 – Marjorie Margolies Mezvinsky (U.S. House of Representatives)

* Online Source: Thomson-West, an article by Laura J. Margulies of Laura J. Margulies & Associates LLC

GENERAL INFORMATION

Please fill out ALL the information requested in these forms. If a question or section does NOT apply to you, write “N/A” in the space. (N/A means “not applicable.”) The more information you provide in these forms, the faster your bankruptcy petition can be prepared. There will be a delay if we need to verify or obtain more information concerning a specific asset, debt or creditor; so please provide as much detail as you can and fill in ALL the information re- quested on these forms. Thank you for taking the time to be thorough and complete, resulting in faster turnaround.

Name, First Middle (spell out) Last
Social Security Number Date of Birth

Street Address

 

City State Zip
County of Residence Length of Time at This Address
Home Phone Other Phone

Email address

MAILING ADDRESS – If you would like any correspondence by the bankruptcy court to be sent to a different mailing address than the physical address you provided above (i.e, PO Box, etc.), please provide that address below:

INFORMATION ABOUT YOUR SPOUSE
 

SPOUSE, First Name

 

Middle (spell out)

 

Last

 

Social Security Number

 

Date of Birth

Address (if living separately)

 

City                                                      State                                           Zip

 

 

Have you resided in the same county for at least 180 days (6 months)?                                            0 Yes    0 No

 

If not, where have you resided?

 

Are you filing this bankruptcy petition with your spouse?                                                                    0 Yes    0 No If “no” please check one:                                       0 Unmarried  0 Spouse filing separately   0 Other Reason Have you filed bankruptcy within the last eight (8) years?                                                                   0 Yes    0 No If “yes” provide date(s):                                                                                                                                                  Have you met the Debt Counseling requirement for your state? Please check one of the choices below:

0 Counseling not completed  0 Received counseling within the past 180 days   0 Request waiver

 

0 Does not apply to my district

 

INFORMATION FOR MEANS TEST

 

 

0 Means Test does NOT apply. Debtor(s) is a disabled veteran with debts incurred primarily during active duty or homeland defense.

 

 

D E P E N D E N T S

Name

 

 

1.                                                 

 

2.                                                 

 

3.                                                 

 

4.                                                 

Age Relationship to You Is this person/child living with you?

 

0 YES       0 NO

 

0 YES       0 NO

 

0 YES       0 NO

 

0 YES       0 NO

 

INCOME FOR SIX (6) MONTHS

 

Provide the total amount of earned income (from all sources) that you received for the current month and last five (5)

months – totaling six (6) months of income. DO NOT DEDUCT TAXES. The income you report below is NOT TAKE-HOME PAY but the TOTAL INCOME YOU ACTUALLY EARNED BEFORE TAXES WERE DEDUCTED.

 

HUSBAND: Wages, salaries, tips, bonuses, overtime and commissions:

 

 

Current Month

 

Last Month

 

2 Months Ago

 

3 Months Ago

 

4 Months Ago

 

5 Months Ago

           

 

WIFE: Wages, salaries, tips, bonuses, overtime and commissions:

 

 

Current Month

 

Last Month

 

2 Months Ago

 

3 Months Ago

 

4 Months Ago

 

5 Months Ago

           

 

HUSBAND: Income from operation of business, profession or farm:

 

Current Month Last Month 2 Months Ago 3 Months Ago 4 Months Ago 5 Months Ago
           

 

WIFE: Income from operation of business, profession or farm:

 

 

Current Month

 

Last Month

 

2 Months Ago

 

3 Months Ago

 

4 Months Ago

 

5 Months Ago

           

 

HUSBAND: Rents and other property income (not rent you paid, but rents paid to you):

 

Current Month Last Month 2 Months Ago 3 Months Ago 4 Months Ago 5 Months Ago
           

 

CONTINUED ON NEXT PAGE

 

 

 

WIFE: Rents and other property income (not rent you paid, but rents paid to you):

 

Current Month Last Month 2 Months Ago 3 Months Ago 4 Months Ago 5 Months Ago
           

 

HUSBAND: Interest income, dividends and royalties:

 

Current Month Last Month 2 Months Ago 3 Months Ago 4 Months Ago 5 Months Ago
           

 

WIFE: Interest income, dividends and royalties:

 

Current Month Last Month 2 Months Ago 3 Months Ago 4 Months Ago 5 Months Ago
           

 

HUSBAND: Pension and retirement income:

 

Current Month Last Month 2 Months Ago 3 Months Ago 4 Months Ago 5 Months Ago
           

 

WIFE: Pension and retirement income:

 

Current Month Last Month 2 Months Ago 3 Months Ago 4 Months Ago 5 Months Ago
           

 

HUSBAND: Income received from others who are not filing bankruptcy with you who contribute money to the household expenses:

 

Current Month Last Month 2 Months Ago 3 Months Ago 4 Months Ago 5 Months Ago
           

 

WIFE: Income received from others who are not filing bankruptcy with you who contribute money to the household expenses:

 

Current Month Last Month 2 Months Ago 3 Months Ago 4 Months Ago 5 Months Ago
           

 

HUSBAND: Unemployment compensation:

 

Current Month Last Month 2 Months Ago 3 Months Ago 4 Months Ago 5 Months Ago
           

 

 

CONTINUED ON NEXT PAGE

 

 

 

WIFE: Unemployment compensation:

 

Current Month Last Month 2 Months Ago 3 Months Ago 4 Months Ago 5 Months Ago
           

 

HUSBAND: Income from other sources not provided for above:

 

Current Month Last Month 2 Months Ago 3 Months Ago 4 Months Ago 5 Months Ago
           

 

WIFE: Income from other sources not provided for above:

 

Current Month Last Month 2 Months Ago 3 Months Ago 4 Months Ago 5 Months Ago
           

 

OTHER INFORMATION

 

 

Has either you or your spouse been known by any other name during the past 8 years?                    0 Yes    0 No

(Example: maiden name, last name from previous marriage, legal name change, etc.) If yes, write the NAME KNOWN AS and DATE(S) THIS NAME WAS USED below:

 

 

 

Name Used                                                                                    Dates Used            


thru                          

 

 

Name Used                                                                                    Dates Used               thru                           

 

 

Has your income significantly increased or decreased during the past six (6) months? If so, please provide details below:

 

NOTICE: IF YOU OWN A MOBILE HOME, PLEASE FILL OUT NEXT PAGE


YOUR REAL ESTATE

 

 

0 Check this box if you have a homestead exemption that exceeds $125,000.00

 

PRINT OUT ADDITIONAL PAGES FOR EVERY SEPARATE PIECE OF REAL ESTATE THAT YOU OWN. Check the type of real estate you own: 0 House  0 Condominium 0 Vacant Lot                   0 Other

Name(s) on Deed or Title                                                                                                                                  

 

Address of Real Estate                                                                                                                                       Description of Real Estate: (example: 1,250 square foot home with 2 bedrooms, 2 baths, attached 2-car garage situated on 2 acres of ground with outbuildings.)                                                                                                                   

 

Name of Mortgage Company                                                                                                                                         Address                                                                                                                                                                          City                                                                                 State                                Zip                                               Account Number                                                           Date obtained this mortgage?                                                 What are the monthly payments? $                What is the pay-off amount on this mortgage?  $                        Are you behind in payments?  0 YES 0 NO  If so, what months?                                                                         What interest rate do you pay?             %          Amount to catch up back payments? $

What year was your real estate last appraised?                What was the appraised value?   $                              

 

Do you have a second mortgage on the real estate?  0 YES  0 NO      Intention: 0 KEEP  0 SURRENDER

 

 

SECOND MORTGAGE INFORMATION (IF APPLICABLE)

 

Name of Mortgage Company                                                                                                                                          Address                                                                                                                                                                         City                                                                                  State                                   Zip                                              

Account Number                                                             Date obtained this mortgage?                                               

 

What are the monthly payments?  $


What is the pay-off amount on this mortgage? $                         

 

 

Are you behind in payments?   0 YES  NO   If so, what months?                                                                  

 

 

What interest rate do you pay?          %          Amount to catch up back payments?


 $                                     

 

 

 

COLLECTION INFORMATION (IF APPLICABLE)

 

 

Name of Collector or Attorney                                                                                                                                        Address                                                                                                                                                                          City                                                                                 State                                Zip                                                Is this real estate in the process of foreclosure or replevin action?  0 YES          0 NO

If in collection, please provide a copy of the court documents you were served.

 

0 Check this box if you have a homestead exemption that exceeds $125,000.00


YOUR MOBILE HOME

 

 

 

PRINT OUT ADDITIONAL PAGES FOR EVERY MOBILE HOMES THAT YOU OWN.

Name(s) on Deed or Title                                                                                                                                    Address of Mobile Home                 Are the wheels completely removed from your mobile home and it is attached to the ground?  0 YES 0 NO Does your mobile home sit in a mobile home park?  0 YES 0 NO  What is the monthly lot rent? $

Does your mobile home sit on a piece of ground you own?  0 YES 0 NO  Size of ground                                     Do you make separate payments for the ground your mobile home sits on?                                                                 If so, explain:                                                                                                                                                                  If you own the ground free and clear, what is the resell value for this piece of ground?                                                 

Description of Mobile Home: (example: 28×40 doublewide, 2 bedrooms, 1 bath, on wheels with skirting and steps and 1 outbuilding shed, situated in mobile home park.)                                                                                                

 

 

Name of Mortgage Company                                                                                                                                          Address                                                                                                                                                                         City                                                                                 State                                Zip                                               Account Number                                                           Date obtained this mortgage?                                                What are the monthly payments? $               What is the pay-off amount on this mortgage? $                        Are you behind in payments?  0 YES 0 NO  If so, what months?                                                                          What interest rate do you pay?               %           Amount to catch up back payments?  $                                   

What year was your mobile home last appraised?                What was the appraised value?  $

 

Do you have a second mortgage on this mobile home?  0 YES         0 NO

SECOND MORTGAGE INFORMATION (IF APPLICABLE)

 

Name of Mortgage Company                                                                                                                                          Address                                                                                                                                                                         City                                                                                  State                                   Zip                                              

Account Number                                                             Date obtained this mortgage?                                               

 

What are the monthly payments?  $


What is the pay-off amount on this mortgage? $                         

 

 

Are you behind in payments?   0 YES  NO   If so, what months?                                                                  

 

 

What interest rate do you pay?          %          Amount to catch up back payments?


 $                                     

 

 

COLLECTION INFORMATION (IF APPLICABLE)

Name of Collector or Attorney                                                                                                                                        Address                                                                                                                                                                          City                                                                                 State                                Zip                                                If in collection, please provide a copy of the court documents you were served.

 

YOUR HOUSEHOLD INVENTORY

 

 

Please check the items below that you currently have in your home. Then, provide the  YARD SALE VALUE of each item — NOT the replacement cost.

 

Yard Sale Value

 

 

0 Stove/Cooking Unit             $                             

0 Refrigerator                        $                             

0 Washer/Dryer                      $                            

0 Microwave                          $                             

0 Cooking Utensils                 $                             

0 Silverware/Flatware             $                             

0 Cookware (Pots/Pans)         $                             

0 Living Room Furniture          $                             

0 Dining Room Furniture         $                             

0 Tables and Chairs                $                             

0 Televisions(s)                      $                             

0 VCR(s)                               $                             

0 DVD(s)                               $                             

0 Compact Disks                   $                            

0 All Other Stereo Equipment  $                              Describe item(s):             

 

0 Bedroom Furniture               $                            

0 Dressers/Nightstands          $                             

0 Lamps and Accessories       $                             

0 Wedding Rings                  $                             

0 Other Jewelry/Watches      $                               Describe item(s):                         


0 Paintings/Art                       $                              Describe item(s):               

 

 

0 Carpenters Tools                 $                               Describe item(s):               

 

 

0 Mechanics Tools                 $                               Describe item(s):               

 

 

0 Guns and Firearms              $                               Describe item(s):               

 

 

0 Lawnmower                        $                             

0 Boats                                  $                             

0 Trailers                               $                             

0 Campers                            $                             

0 Yard Tools/Equipment         $                             

0 Swimming Pool                   $                             

0 Cell Phones                       $                             

 

 

OTHER ASSETS

0 Government Bonds $                            
0 Certificate of Deposits $                           
0 Copyrights/Patents $                           
0 Aircraft $                            
0 Interests in education IRA $                           
0 Customer lists $                           
0            $                            
0            $                            
0            $                            
0            $                            
0            $                            
0            $                            
0            $                            
0            $                            

 

0 Rent deposit with landlord   $                               Name of Landlord                                                   Address                                                            City                 State                        Zip         

 

 

0 Furs                                   $                             

0 Computer(s)                       $                             

0 Computer Printers               $                            

0 Desks/Office Furniture         $                             

0 Other Computer Equipment  $                             Describe item(s):                                                            

 

 

0 Photography Equipment      $                             

0 Satellite Disks                    $                            

0 All Clothing                       $                               (including shoes, coats, hats, etc.)

0 Collectibles                        $                               Describe item(s):                                                            

 

                 YOUR MOTOR VEHICLES                 

 

Motor vehicles include cars, trucks, SUV’s, motorcycles, mobile homes, boats, trailers, campers, etc. that are

TITLED IN YOU (OR YOUR SPOUSE’S NAME) Print out more sheets if you own more than 2 vehicles.

 

Type:  0Automobile   0 Truck    0 Motorcycle    0 Mobile Home   0 Other:

 

Year                                                Make                                                            Model                                            Condition   0 Excellent    0 Good    0 Fair    0 Poor    0 Not Running             Mileage                                           Name(s) on vehicle title?                                                                                                                                                Is vehicle leased?  0 YES  0 NO  If yes, what is the “buy out” on the lease?                                                          Name of company you make payments to for this vehicle:                                                                                            Address                                                                                                                                                                          City                                                                                   State                                             Zip                                  

Account Number                                                               Date Established Loan                                                        

 

 

Monthly Payment  $                     


 

How many months are you behind in payments?                                            

 

 

What is the “pay off” amount on this vehicle?   $                              


 

Check one:  0 Keep    0 Surrender

 

 

Have you went to a loan company and listed this vehicle as collateral for a personal loan?    0 YES  0NO

 

If so, name of loan company for personal loan:                                                                                                   

 

 

 

Type:  0Automobile   0 Truck    0 Motorcycle    0 Mobile Home   0 Other:

 

Year                                                Make                                                            Model                                            Condition   0 Excellent    0 Good    0 Fair    0 Poor    0 Not Running             Mileage                                           Name(s) on vehicle title?                                                                                                                                                Is vehicle leased?  0 YES  0 NO  If yes, what is the “buy out” on the lease?                                                          Name of company you make payments to for this vehicle:                                                                                            Address                                                                                                                                                                          City                                                                                   State                                             Zip                                  

Account Number                                                               Date Established Loan                                                        

 

 

Monthly Payment  $                     


 

How many months are you behind in payments?                                            

 

 

What is the “pay off” amount on this vehicle?   $                              


 

Check one:  0 Keep    0 Surrender

 

 

Have you went to a loan company and listed this vehicle as collateral for a personal loan?    0 YES  0NO

 

If so, name of loan company for personal loan:                                                                                                   

 

 

Name of Creditor                                                                                                                                                            Address                                                                                                                                                                          City                                                                                   State                                 Zip                                             Total amount you owe on this debt                                 Account No:                                                                          Date (or year) you originally obtained this debt or established credit:                                                                            If this debt is for a credit card, what date (or year) did you last make a purchase?                                                       What is this debt for?                                                                                                                                                     Who is financially responsible for this debt? 0 HUSBAND  0 WIFE  0 BOTH  0 OTHER                                     Has this debt been turned over to a collection agency?    0 YES     0 NO

Name of collection agency or law firm                                                                                                                            Address                                                                                                                                                                        

City                                                                                   State                                    Zip                                            

 

 

Name of Creditor                                                                                                                                                            Address                                                                                                                                                                          City                                                                                   State                                 Zip                                             Total amount you owe on this debt                                 Account No:                                                                          Date (or year) you originally obtained this debt or established credit:                                                                            If this debt is for a credit card, what date (or year) did you last make a purchase?                                                       What is this debt for?                                                                                                                                                     Who is financially responsible for this debt? 0 HUSBAND  0 WIFE  0 BOTH  0 OTHER                                     Has this debt been turned over to a collection agency?    0 YES     0 NO

Name of collection agency or law firm                                                                                                                            Address                                                                                                                                                                        

City                                                                                   State                                    Zip                                            

 

Name of Creditor                                                                                                                                                            Address                                                                                                                                                                          City                                                                                   State                                 Zip                                             Total amount you owe on this debt                                 Account No:                                                                          Date (or year) you originally obtained this debt or established credit:                                                                            If this debt is for a credit card, what date (or year) did you last make a purchase?                                                       What is this debt for?                                                                                                                                                     Who is financially responsible for this debt? 0 HUSBAND  0 WIFE  0 BOTH  0 OTHER                                     Has this debt been turned over to a collection agency?    0 YES     0 NO

Name of collection agency or law firm                                                                                                                            Address                                                                                                                                                                         City                                                                                   State                                    Zip                                            

 

 

Name of Creditor                                                                                                                                                            Address                                                                                                                                                                          City                                                                                   State                                 Zip                                             Total amount you owe on this debt                                 Account No:                                                                          Date (or year) you originally obtained this debt or established credit:                                                                            If this debt is for a credit card, what date (or year) did you last make a purchase?                                                       What is this debt for?                                                                                                                                                     Who is financially responsible for this debt? 0 HUSBAND  0 WIFE  0 BOTH  0 OTHER                                     Has this debt been turned over to a collection agency?    0 YES     0 NO

Name of collection agency or law firm                                                                                                                            Address                                                                                                                                                                        

City                                                                                   State                                    Zip                                            

 

 

Name of Creditor                                                                                                                                                            Address                                                                                                                                                                          City                                                                                   State                                 Zip                                             Total amount you owe on this debt                                 Account No:                                                                          Date (or year) you originally obtained this debt or established credit:                                                                            If this debt is for a credit card, what date (or year) did you last make a purchase?                                                       What is this debt for?                                                                                                                                                     Who is financially responsible for this debt? 0 HUSBAND  0 WIFE  0 BOTH  0 OTHER                                     Has this debt been turned over to a collection agency?    0 YES     0 NO

Name of collection agency or law firm                                                                                                                            Address                                                                                                                                                                        

City                                                                                   State                                    Zip                                            

 

Name of Creditor                                                                                                                                                            Address                                                                                                                                                                          City                                                                                   State                                 Zip                                             Total amount you owe on this debt                                 Account No:                                                                          Date (or year) you originally obtained this debt or established credit:                                                                            If this debt is for a credit card, what date (or year) did you last make a purchase?                                                       What is this debt for?                                                                                                                                                     Who is financially responsible for this debt? 0 HUSBAND  0 WIFE  0 BOTH  0 OTHER                                     Has this debt been turned over to a collection agency?    0 YES     0 NO

Name of collection agency or law firm                                                                                                                            Address                                                                                                                                                                         City                                                                                   State                                    Zip                                            

 

 

Name of Creditor                                                                                                                                                            Address                                                                                                                                                                          City                                                                                   State                                 Zip                                             Total amount you owe on this debt                                 Account No:                                                                          Date (or year) you originally obtained this debt or established credit:                                                                            If this debt is for a credit card, what date (or year) did you last make a purchase?                                                       What is this debt for?                                                                                                                                                     Who is financially responsible for this debt? 0 HUSBAND  0 WIFE  0 BOTH  0 OTHER                                     Has this debt been turned over to a collection agency?    0 YES     0 NO

Name of collection agency or law firm                                                                                                                            Address                                                                                                                                                                        

City                                                                                   State                                    Zip                                            

 

 

Name of Creditor                                                                                                                                                            Address                                                                                                                                                                          City                                                                                   State                                 Zip                                             Total amount you owe on this debt                                 Account No:                                                                          Date (or year) you originally obtained this debt or established credit:                                                                            If this debt is for a credit card, what date (or year) did you last make a purchase?                                                       What is this debt for?                                                                                                                                                     Who is financially responsible for this debt? 0 HUSBAND  0 WIFE  0 BOTH  0 OTHER                                     Has this debt been turned over to a collection agency?    0 YES     0 NO

Name of collection agency or law firm                                                                                                                            Address                                                                                                                                                                        

City                                                                                   State                                    Zip                                            

 

Name of Creditor                                                                                                                                                            Address                                                                                                                                                                          City                                                                                   State                                 Zip                                             Total amount you owe on this debt                                 Account No:                                                                          Date (or year) you originally obtained this debt or established credit:                                                                            If this debt is for a credit card, what date (or year) did you last make a purchase?                                                       What is this debt for?                                                                                                                                                     Who is financially responsible for this debt? 0 HUSBAND  0 WIFE  0 BOTH  0 OTHER                                     Has this debt been turned over to a collection agency?    0 YES     0 NO

Name of collection agency or law firm                                                                                                                            Address                                                                                                                                                                         City                                                                                   State                                    Zip                                            

 

 

 

Your Name as listed on your current paycheck stub:                                                                                                    Year-to-Date Total for this current year?                                                                                                                   VERY IMPORTANT:     Gross Income last year                                  Gross Income 2 Yrs Ago                           Employer’s Name

Address                                                                                                                                                                         City, State, Zip                                                                                                                                                               Telephone Number

Length of Time at This Job?                                  Years                     Months                                                          Job Title (do not abbreviate)                                                                                                                                           How often do you get paid? (circle or check one)

0 every week                   0 bi-weekly (sometimes I get paid 3 times a month              0 once a month

 

0 semi-monthly (on the same 2 days of each month)

 

What is your “average” gross wages before deductions?

 

How much “average” extra money do you receive in overtime and commissions per pay period?                                             What is the total amount of taxes deducted (FICA, Federal, State, Local) from your paycheck?                                                  How much Insurance is deducted from your paycheck?                              How much in Union Dues?

How much do you pay in Alimony or Child Support if any?                     Are you court ordered to pay this?   0 YES  0 NO

 

Are there any other deductions from your paycheck?    0 YES   0 NO   If yes, how much?

 

What is this “other” deduction for?                                        If 401K Plan, how long have you participated?                               How much additional income do you make monthly from a business, flea market, etc?                                                            Monthly Income from real property (rentals)                                  Monthly Interests and Dividends                                          Monthly Alimony or Child Support received                                    Monthly Social Security

Monthly Government Assistance                                                    Monthly Food Stamps

 

Monthly Public Assistance                                                               Monthly Pension or Retirement                                            Other Income (Reason and amount received monthly)?                                                                                                              

 

 

Do you have a second job?    0 YES      0 NO     If yes, name of employer:                                                                               Address                                                                                                                                                                         City, State, Zip

Telephone Number                                                                                                                                                         Length of Time at This Job?                         Job Title

How often do you get paid? (check one)

 

0 every week                   0 bi-weekly (sometimes I get paid 3 times a month              0 once a month

 

0 semi-monthly (on the same 2 days of each month)

 

What is your “average” gross wages before deductions?                                                                                                              Do you receive any income from a home-based business?    0 YES         0 NO      How much per month?                            

 

INCOME HISTORY FOR YOUR SPOUSE

 

Your Name as listed on your current paycheck stub:                                                                                                    Year-to-Date Total for this current year?                                                                                                                   VERY IMPORTANT:     Gross Income last year                                  Gross Income 2 Yrs Ago

Employer’s Name

 

Address                                                                                                                                                                         City, State, Zip                                                                                                                                                               Telephone Number

Length of Time at This Job?                                  Years                     Months                                                          Job Title (do not abbreviate)                                                                                                                                           How often do you get paid? (circle or check one)

0 every week                   0 bi-weekly (sometimes I get paid 3 times a month              0 once a month

 

0 semi-monthly (on the same 2 days of each month)

 

What is your “average” gross wages before deductions?

 

How much “average” extra money do you receive in overtime and commissions per pay period?

 

What is the total amount of taxes deducted (FICA, Federal, State, Local) from your paycheck?                                                  How much Insurance is deducted from your paycheck?                              How much in Union Dues?

How much do you pay in Alimony or Child Support if any?                     Are you court ordered to pay this?   0 YES  0 NO

 

Are there any other deductions from your paycheck?    0 YES   0 NO   If yes, how much?

 

What is this “other” deduction for?                                        If 401K Plan, how long have you participated?                               How much additional income do you make monthly from a business, flea market, etc?                                                           Monthly Income from real property (rentals)                                  Monthly Interests and Dividends                                          Monthly Alimony or Child Support received                                    Monthly Social Security

Monthly Government Assistance                                                    Monthly Food Stamps

 

Monthly Public Assistance                                                               Monthly Pension or Retirement                                            Other Income (Reason and amount received monthly)?                                                                                                              

 

 

Do you have a second job?    0 YES      0 NO     If yes, name of employer:                                                                               Address                                                                                                                                                                         City, State, Zip

Telephone Number                                                                                                                                                         Length of Time at This Job?                         Job Title

How often do you get paid? (check one)

 

0 every week                   0 bi-weekly (sometimes I get paid 3 times a month              0 once a month

 

0 semi-monthly (on the same 2 days of each month)

 

What is your “average” gross wages before deductions?                                                                                                              Do you receive any income from a home-based business?    0 YES        0 NO     How much per month?

 

HOME BASED BUSINESS OWNERS

 

If you have operated a business inside or outside of your home during the past 12 months, please list below the normal income and expenses your business generated for an average month. If you did not have an average monthly income due to extreme highs and lows in your business, estimate your total yearly income and divide by

12 to get the average monthly income. Use the same method of determining your average monthly expenses and enter those figures into the spaces below:

 

 

Average monthly business income

 

Did you withhold any earnings for tax purposes? 0 Yes  0 No

$                                        
 

If yes, how much did you withhold monthly?

$                                        
 

Average monthly business expenses (if applicable)

 
 

Rent and utilities

$                                        
 

Office Supplies

$                                        
 

Product Supplies

$                                        
 

Wages

$                                        
 

Equipment Leases

$                                        
 

Other Business Leases

$                                        
 

Other                                                                            

$                                        
 

Other                                                                            

$                                        
 

Other                                                                            

$                                        
 

Other                                                                            

$                                        
 

Other                                                                            

$                                        
 

Other                                                                            

$                                        
 

Other                                                                            

$                                        
 

Other                                                                            

$                                        
 

Total Average Monthly Income

$                                        
 

Total Average Monthly Expenses

$                                        
 

Average Monthly Business Profit

$                                        

 

Did you file income taxes for the years you operated your business?  0 Yes  0 No

 

If not, what years did you NOT file taxes?                                                                                               

 

MONTHLY BUDGET

This form is necessary to determine how much you spend each month on living expenses. Be sure to write in the MONTHLY (not yearly) amounts in the spaces below each expenditure. For utilities, your bill may be higher in the winter than in the summer, so write an amount that is “average” covering the whole 12 month period.

 

 

Housing Expenses

Rent (if you do not own your home)           $                 First Mortgage payment or mobile

home monthly payment                            $               

Second mortgage (if applicable)               $                 Third mortgage (if applicable)      $         

Lot Payment (if applicable)                       $                 Are real estate taxes included in

your mortgage payment?       0 Yes         0 No

Taxes not included in house payment        $               


Taxes

Are any other taxes deducted from your wages? If so, what type of taxes are they?          $         

 

 

Other Expenses

 

Alimony or Child Support                         $                 Payments for someone outside

your home                                               $               

Union Dues (not payroll deducted)            $               

 

Professional Dues (not payroll deducted)   $              

 

Is your home insurance included in

your mortgage payment?       0 Yes         0 No Insurance not included in house payment  $       Utilities (Normal Monthly Average)

Electricity and Gas                                    $                  Water                                                          $                  Telephone (Basic Service)                          $                  Trash Pick-Up                                            $                  Basic Needs

Home Maintenance (home owners)            $               

 

Food (Monthly)                                        $               


Child Care Expenses                                 $                  Babysitter/Day Care Expenses                  $                  School Expenses                                       $                  School Lunch Expenses                            $                  College Tuition (Not Loans)                        $                  Student Loan Repayment                           $                  Newspapers, Books, Magazines                $                  Personal Care Items                                   $                  Other                                                           $                  Other                                                           $                 

 

 

Clothing (Monthly Expense)                       $                  Laundry, dry cleaning, soap, etc.               $                  Medical expenses not paid by insurance   $                  Transportation

Gasoline/auto maintenance                        $                  Recreation, Entertainment                         $                  Charitable Giving (if claimed on taxes)       $                  Insurance

Renters Insurance                                      $                  Life Insurance (other than employer)          $                  Health Insurance (other than employer)      $                  Automobile Insurance                                 $                  Other Insurance                                          $                 


Use the space below to describe any additional

monthly expenses that you must pay out of your pocket that are not covered here. Explain the type of expense, amount of expense and how long you will continue to have this expense:

 

The following pages contain extremely IMPORTANT QUESTIONS, many of which will be asked you again by the Trustee when you attend your first hearing. Please take your time and go through every question thoroughly and provide as much detail as possible to the questions you answer “yes” to.

 

List the names of all spouses (past and present) that you have been married to, as well as the dates you were married to this spouse:

Full Name (First, Middle, Last)                                                                                                                                      Dates Married:                      From                                         To                                         

Full Name (First, Middle, Last)                                                                                                                                      Dates Married:                      From                                         To                                         

Full Name (First, Middle, Last)                                                                                                                                      Dates Married:                      From                                         To                                         

Full Name (First, Middle, Last)                                                                                                                                       Dates Married:                      From                                          To                                         

 

Have you ever provided a notice to any governmental unit of a

Release of Hazardous Materials?                                                                                                  0 Yes    0 No If so, list the name and address of every site for which you have provided notice to a governmental unit of a release of Hazardous Material. Indicate the governmental unit to which the notice was sent and the date of the notice.

Name/Address of Site                                                                                                                                                    Governmental Unit Notice Sent To                                                                                                                                  Date Notice Sent to Governmental Unit                                                                                                                         

 

Do you share the ownership of any real property with another person, such as

a co-tenancy or joint tenancy? (This does not apply to your spouse.)                                       0 Yes    0 No

Name of person                                                                                                                                                            

 

Do you have a future interest in any real estate, such as putting money

down on a property you have not purchased yet?                                                                      0 Yes    0 No

If so, provide details:                                                                                                                                                     

 

Do you own or are you buying a time-share in a vacation property or resort?                       0 Yes    0 No

If so, provide details:                                                                                                                                                      

 

Do you have a car, truck, motorcycle, boat or camper in your possession titled

in someone else’s name?                                                                                                               0 Yes    0 No Year, Make, Model of Vehicle                                                                                                                                         Whose name is the motor vehicle titled to?                                                                                                                  

Address                                                                                                                                                                         City                                                                                        State                         Zip                                                 What is this person’s relationship to you?                                                                                                                     Why are you holding this property?                                                                                                                              

 

 

 

Are you buying any of your furniture or appliances with installment payments?                      0 Yes    0 No

 

Description of Item(s)

 

1.                                                                                                                   Yard Sale Value                          

 

2.                                                                                                                    Yard Sale Value                          

 

3.                                                                                                                    Yard Sale Value                         

 

Name of company you make installment payments to:                                                                                                

 

** MAKE SURE TO LIST THESE DEBTS ON THE DEBT SHEETS.

 

 

Are you renting-to-own any of your furniture or appliances?                                                    0 Yes    0 No

 

Description of Item(s)

 

1.                                                                                                                              Yard Sale Value                          

 

2.                                                                                                                              Yard Sale Value                           

 

3.                                                                                                                    Yard Sale Value                            Name of company you make installment payments to:                                                                                                      

** MAKE SURE TO LIST THES DEBTS ON THE DEBT SHEETS.

 

 

Have you gone to a loan company or bank and listed any of your furniture,

appliances or personal possessions at the time you obtained the loan?                                  0 Yes    0 No

Description of Item(s)

 

1.                                                                                                                               Yard Sale Value                          

 

2.                                                                                                                               Yard Sale Value                           

 

3.                                                                                                                      Yard Sale Value                          Name of company you make installment payments to:                                                                                                      

** MAKE SURE TO LIST THES DEBTS ON THE DEBT SHEETS.

 

 

Do you own or are you buying any tools or equipment that you use for your work?              0 Yes    0 No Description of Item(s):                                                                                                                                                    Value of the item if sold at a flea market or yard sale:                                                                                                   If making payments on, who do you pay?                                                                                                                     

** MAKE SURE TO LIST THESE DEBTS ON THE DEBT SHEETS

 

 

At present, do you have any inventory (stock in trade) that could be sold for

$200 or more in profit?                                                                                                                    0 Yes    0 No Description of Item(s)                                                                                                                                                     Value of the item if sold at a flea market or yard sale                                                                                                   

 

 

 

Are you buying any jewelry with installment payments?                                                           0 Yes    0 No

 

Description of Item(s)

 

1.                                                                                                                              Yard Sale Value                           

 

2.                                                                                                                              Yard Sale Value                           

 

3.                                                                                                                            Yard Sale Value                            Name of company you make installment payments to:                                                                                                

** MAKE SURE TO LIST THESE DEBTS ON THE DEBT SHEETS.

 

 

Do you have any animals, livestock or pets you could sell for $200 or more?                         0 Yes    0 No Description of Animal(s)                                                                                                                                                 Value of the animals if you had to sell them                                                                                                                  

 

 

Do you have any checking or savings account(s) at this time?                                                  0 Yes    0 No Name of Bank                                                                                                                                                                Address of Branch:                                                                                                                                                         City                                                                                       State                          Zip                                                Type of account: Checking, Savings or Both?                                                                                                               Name(s) on the Account                                                                                                                                                 Account Number for Checking                                                                   Present Balance                                       Account Number for Savings (if applicable)                                               Present Balance                                        Name of Second Bank (if applicable)                                                                                                                       Address of Branch:                                                                                                                                                        City                                                                                       State                         Zip                                                 Type of account: Checking, Savings or Both?                                                                                                              Name(s) on the Account                                                                                                                                                Account Number                                                                                         Present Balance                                       

 

 

Have you closed any bank accounts within the past two (2) years?                                          0 Yes    0 No Name of Bank                                                                                                                                                                Address of Bank                                                                                                                                                             City                                                                                        State                         Zip                                                Account Number                                   Date Closed                    Name on Account                                                Did you owe a balance when you closed this account?  0Yes  0 No   Balance owed:                                           If you did not owe a balance when you closed this account, how much money did you receive?                                 

 

 

 

Do you or have you rented a safe deposit box during the past two (2) years?                        0 Yes    0 No Name of Financial Institution                                                                                                                                          Address of Financial Institution                                                                                                                                      City                                                                                       State                         Zip                                                What are the contents of the safe deposit box?                                                                                                            

 

What monthly amount do you pay for rental of this deposit box?                                                                                  If you no longer have the safe deposit box, what date/year did you surrender it?                                                         

If you transferred the safe deposit box, who did you transfer it to?                                                                               

 

 

Do you have a Christmas Club Account or any other special purpose accounts?                   0 Yes    0 No Name of Financial Institution                                                                                                                                         Address                                                                                                                                                                          City                                                                                        State                         Zip                                                Type of account:                                                              Account Number                                                                  Name(s) on the Account                                                                       Present Balance                                              

 

Do you currently have any security deposits being held by a utility company?                      0 Yes    0 No If yes, what is the amount?                                 Name of Utility Company:                                                                Address of Utility Company                                                                                                                                          

City                                                                                       State                            Zip                                                

 

Account Number                                                                                   Present Balance                                             

** Remember to include any past-due utility bills that you owe from previous addresses on your Debt Sheets.

 

 

Do you have any life insurance?                                                                                                   0 Yes    0 No Name of Insurance Company                                                                                                                                         If a “whole life” policy — what is the current cash value?                                                                                                If your life insurance is only payable upon death, what is the face value of the policy?                                                 Who is the beneficiary?                                                                                       Relationship                                       

** If you have other life insurance policies, please list the information above for each one on BACK of this page.

 

 

Do you or your spouse participate in a retirement, 401K or pension plan?                             0 Yes    0 No Type of pension plan (i.e., 401-K, PERS, etc.)                                                                                                              When did you first enroll in this plan?                                                       Current cash value:                                      

 

 

 

Have you set up your own separate retirement not provided by employer?                           0 Yes    0 No Name of Financial Institution (if applicable)                                                                                                                   Amount in this separate retirement account?                            Who is the beneficiary?                                              

 

Will you be receiving retirement benefits from a previous employer within the

next six (6) months?                                                                                                                        0 Yes    0 No

Date you expect to start receiving retirement benefits:                                                                                                 

 

 

Do you have any stocks, bonds (including savings bonds) or mutual funds?                           0 Yes    0 No Type of bond, stock, mutual fund:                                                                                                                                  Does this bond, stock or mutual fund have a cash value?   0Yes   0 No  Cash value:                                             

 

 

Does you have a cell phone?                                                                                                         0 Yes    0 No Name of cell phone company                                                                                                                                         Address                                                                                                                                                                          City                                                                                        State                         Zip                                                Account Number                                                                   Date contract began                                                      Is this a month-to-month contract?           0 Yes      0 No

If not, what is the length of the contract?   0 1 year      0 2 years     0 3 years     0 Other:                                    What is the normal monthly contract payment? (i.e.: $19.95, $29.95, etc)                                                                   Do you wish to keep the cell phone and continue paying the monthly contract?                               0 Yes    0 No

** If you have more than one cell phone, list the same information above on the BACK of this page.

 

 

Do you live with a roommate/relative that pays part of your expenses?                                  0 Yes    0 No

 

Name of roommate or relative:                                                                  Relationship?

 

What expenses do they pay?                                                                                                                                       

 

 

What is the total amount they contribute on a monthly basis to your living expenses? How long have they been paying this amount?                  From                          To

 

 

Do relatives or other parties help to pay part or all of your monthly expenses?                     0 Yes    0 No

 

Name of relatives providing additional support: Relationship of this relative to you:

What is the total amount they contribute on a monthly basis to your living expenses?                                                How long have they been paying this amount?          From                              To                                     

 

 

 

Are you currently attending college?                                                                                       0 Yes    0 No Name of college                                                                                                                                                              Anticipated graduation date                                                       Major of Study                                                  

 

 

Do you have a student loan?                                                                                                   0 Yes    0 No Name of institution you will make payments to:                                                                                                                 Address                                                                                                                                                                            City    State                                                                             Zip                                                       Date student loan first obtained?                                                                                 Date payment is/was to begin:                             Total amount to pay off student loan                                                    Average monthly payment                                 

 

 

Do you currently owe any fines? (includes parking tickets, moving violations, etc)                 0 Yes    0 No Name of court you owe fines to                                                                                                                                         Address                                                                                                                                                                            City                                                                                        State                          Zip                                             Date of occurrence                                                                         Amount owed                                                           Case number assigned by court                                                   Name of party 0 Husband 0Wife 0 Other

What was this fine for?                                                                                                                                      

 

 

If you pay child support, are you currently behind in any payments?                                      0 Yes    0 No Name of person/agency you pay child support to                                                                                                               Address                                                                                                                                                                             City                                                                                         State                         Zip                                              What is the total amount you owe in back child support?                                                                                       What date (or year) were you supposed to start paying child support?                                                                              If so, what are the payment arrangements?                                                                                                                                    

 

Even if you never expect to collect any money, does an ex-spouse owe you

money for alimony or child support?                                                                                      0 Yes    0 No Name of Ex-Spouse                                                                                                                                                         Address of Ex-Spouse                                                                                                                                                   

City                                                                                     State                         Zip                                                Total amount he/she owes you                                         Date originally started owing you                                         Has this ex-spouse been court ordered to pay you?                                        Year of court order?                             

 

 

 

Over the last year, have you, your children or your spouse been involved in

an accident where someone was hurt, for example, a car accident?                                       0 Yes    0 No Date accident occurred                                        Who was at fault?                                                                          Who was involved in the accident?                                                                                                                               

Was any insurance money received?  0Yes  0 No   If yes, how much?                                                                   

 

 

During the next six (6) months, do you expect to inherit anything?                                          0 Yes    0 No How much do you expect to inherit?                                                                Date expected                                    Reasons for inheritance                                                                                                                                                 

 

During the next six (6) months, do you expect to recover on

anyone’s life insurance policy?                                                                                                     0 Yes    0 No How much do you expect to receive?                                                               Date expected                                    Reasons for receiving this money:                                                                                                                                

 

 

Do you expect to receive any money from any insurance claim,

for any reason, during the next six (6) months?                                                                           0 Yes    0 No How much do you expect to receive?                                                               Date expected                                    Reasons for receiving this money:                                                                                                                                 

 

 

Are you the beneficiary of a trust fund?                                                                                        0 Yes    0 No What is the amount of the trust fund?                          Name of trust fund owner                                                        Relationship to you:                                              When will you have access to this trust fund?                                

 

Are you owed any back wages, commissions, or vacation

pay from your current or previous employer?                                                                             0 Yes    0 No Employer Name                                                                                                                                                             Amount expected to receive                                                             Date expected to receive                                     

** Provide details about this amount owed you. (Feel free to use the back of this page if necessary)

 

 

Is any of your property in the hands of a repairman, storage

company or pawnbroker?                                                                                                               0 Yes    0 No Name of Place Holding Your Property                                                                                                                            Address                                                                                                                                                                         

City                                                                                     State                         Zip                                                Description of Items and yard sale value:

1.                                                                                                                  Yard Sale Value                                        

 

 

 

2.                                                                                                                  Yard Sale Value                                        

 

3.                                                                                                               Yard Sale Value                                        What is the total amount you need to pay in order to get these items released?                                                         

 

 

In the near future, do you expect to settle, win or begin a case for personal injury?            0 Yes    0 No How much do you expect to receive?                                  Date you expect to receive this money?                          Provide details about this personal injury claim:                                                                                                            Name of attorney or law firm handling this claim?                                                                                                         

 

In the near future, do you expect to enter into any property settlement

with a former spouse?                                                                                                                     0 Yes    0 No

List all items you expect to receive or turn over in the property settlement (including cash):                                       

 

 

What is the total market value (yard sale value) of these items?                                                                                   When do you expect to receive this money or property? or                                                                                           When do you expect to turn over this cash or property?                                                                                              

 

 

Does anyone owe you any money for a judgment you have obtained against them?           0 Yes    0 No Name of party you filed a lawsuit on                                                                                                                              Address                                                                                                                                                                         City                                                                                       State                         Zip                                                 Date you filed this lawsuit?                                   Money amount awarded you in judgment:                                        

 

Even if you never expect to collect, does anyone owe you

any money for any reason whatsoever?                                                                                       0 Yes    0 No Name of Person who owes you money                                                                                                                          Address                                                                                                                                                                         

City                                                                                      State                         Zip                                                 Explain why they owe you money:                                                                                                                                Amount they owe you                                           Date they originally started owing you                                             

 

Have you made any payments on your loans or bills other than ordinary payments? In other words, have you made catch-up payments, paid off or borrowed to pay on or off bills or loans?              0 Yes    0 No

Name of Creditor You Paid                                                                                                                                            Date Paid                                                     Amount Paid                                  Current Balance Due                       Name of Creditor You Paid

Date Paid                                                     Amount Paid                                     Current Balance Due                     

 

 

 

Are there any lawsuits pending against you now?                                                                      0 Yes    0 No Name of party suing you (Plaintiff)?                                                                                                                                Case Number                                                                                Date Lawsuit Filed                                                 Type of Lawsuit From Court Pleading (Complaint, Summons, etc.)                                                                               Attorney for the Plaintiff (found on court pleading):                                                                                                         Address                                                                                                                                                                         City                                                                                       State                         Zip                                                Court when lawsuit was filed (at the top of the pleading)                                                                                                Address                                                                                                                                                                         City                                                                                        State                            Zip                                               

** If lawsuit is LESS THAN 1 YEAR OLD, please make a copy and include with these forms

 

 

Have your wages or property been garnisheed or attached?                                                    0 Yes    0 No Who garnisheed your wages or attached your property?                                                                                               When item did they repossess? (If car, provide the year, make, model)                                                                        How much money do they take from your paycheck?                              How often is this deducted?                         

 

Have you returned any property to creditors or was any of your property repossessed from you, sold at foreclosure, transferred through a deed or returned to a seller?                                              0 Yes    0 No

What property did you turn over to a receiver?                                                                                                              When and where did this take place?                                                                                                                           

 

 

Is any of your property in receivership or other legal custody?                                                 0 Yes    0 No When did you file your receivership?                                                                                                                             In what court was this done?                                                                                                                                         

 

 

Have you made any gifts to friends or relatives?                                                                         0 Yes    0 No What gifts or transfers have you made?                                                                                                                        Who did you give the gift to?                                                                                                                                         What date/year did you make the gift?                                  What is the approximate value?                                       

 

Have you transferred any money or property to family members or

friends or paid them any money on debts you might owe them?                                             0 Yes    0 No Type of property transferred:                                                                                                                                           What date/year was it transferred?                                          What is the approximate value?                                   

 

 

 

Have you have any unusual losses, such as fire, theft, gambling or otherwise?                     0 Yes    0 No Type of loss?    0 Fire      0 Theft      0 Gambling      0 Other:                                                                               What item(s) or amount of money was lost?                                                                                                                 What date/year was it lost?                                                            Amount insurance paid?                                        

 

 

Have you had any losses covered by insurance?                                                                        0 Yes    0 No Describe loss:                                                                                                                                                                Date/year of loss?                                                                           Amount insurance paid?                                        

 

Have you consulted with any other attorney about your financial affairs or

paid money to a debt counseling service?                                                                                   0 Yes    0 No Name of attorney or service                                                                                                                                           Address                                                                                                                                                                         

City                                                                                      State                         Zip                                                Consultation Date                                                                           Total paid for service                                             

 

 

Have you filed any bankruptcy within the last eight (8) years?                                                  0 Yes    0 No Did you file a Chapter 7, Chapter 13, or a Chapter 11?                                                                                                  Date your bankruptcy was filed?                                                   City, State Filed?                                                   Name(s) of persons who filed?                                                                                                                                       Was the case discharged?     0 Yes    0 No     Case Number                                                                                 

 

 

Is anyone holding any property that belongs to you?                                                                 0 Yes    0 No

 

Item(s) in someone else’s possession that belong to you?                                                                                          

 

 

Name of person holding these items:                                                                                                                             Address                                                                                                                                                                         City                                                                                        State                           Zip                                               

 

Beside your current address, have you lived at any other

addresses within the past six (6) years?                                                                                        0 Yes    0 No Previous Address lived at:                                                                                                                                              City                                                                                        State                            Zip                                                

Time period lived at this address: From (date/year)                                              To (date/year)                                Name(s) of parties who lived at this address:                                                                                                               

 

 

 

Previous Address lived at:                                                                                                                                              City                                                                                       State                         Zip                                                Time period lived at this address: From (date/year)                                              To (date/year)                                Name(s) of parties who lived at this address:                                                                                                               

 

 

Previous Address lived at:                                                                                                                                              City                                                                                       State                         Zip                                                 Time period lived at this address: From (date/year)                                              To (date/year)                                Name(s) of parties who lived at this address:                                                                                                               

 

Have you been self-employed or had any financial interest in any business (or been involved in a partnership with someone who owned a business) within the past eight (8) years?               0 Yes    0 No

Name of business                                                                                                                                                          Business address                                                                                                                                                          Type of business (what type of products were sold)?                                                                                                    Date business began                                                             Date business ended                                                     Name of your partners, co-investors, or associates?                                                                                                     What were your net profits for this year?                          Last year?                             2 Yrs Ago?                           How much income tax do you pay from the income you make with your business?                                                    

 

During the past two (2) years, have either you or your spouse had any other income source outside normal pay from your employer? (includes fleasda market dealers)                                              0 Yes    0 No

Income this year?                                                   Last year?                                    2 Yrs Ago?                                 

 

as

By signing below, I state that all the information provided in the pages of the “Statement of

Affairs” is true and correct to the best of my knowledge.

 

 

 

 

Signature of Debtor #1                                                           Signature of Debtor #2

 

 

Date:                                                                                       Date: