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Bankruptcy Worksheet

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					                    Bankruptcy Worksheet
                     MICHAEL SCOTT ZIMMERER, P.C.
                                  110 Broadway, Suite 510
                                  San Antonio, Texas 78205
                                      T: (210) 224-7660
                                      F: (210) 490-4590
                                         www.msz-law.com
                                                   

                                     INSTRUCTIONS
Please answer these questions as carefully as possible. The information you give us will be used
to compile the schedules the Court requires to have your bankruptcy case approved. Your answer
will determine what will be on your bankruptcy petition. Any errors, omissions or misrepresentations
may seriously affect your discharge of debts.

Where space permits, answer the questions on this questionnaire. If additional space is necessary,
use a separate sheet or the back of this form identifying by number and letter the question
answered. Please use all the space needed to answer all questions and parts of questions as
completely as possible. Do not let the size of the space given to answer determine the extent of
your response. A question asking a date, or when something happened, can usually be answered
with the month and year only. A question asking for an address must include the zip code, along
with complete street or post office box address.

Remember, these questions must be answered fully and accurately. Failure to supply information
will necessitate whatever additional contact with our firm as is required to obtain it. If you absolutely
cannot remember, or find out, or guess with reasonable accuracy, answer "Unknown." The effort
expended on this questionnaire will help determine how quickly your bankruptcy can be filed and
how complete your discharge will be.

There are many parts of the worksheet that will ask you to place a value on property that you own.
Please use the following as a guideline for determining those values:

Personal Property & Household Goods: When filling out this part of the worksheet, use the
fair market value. Remember, it is not what the item is worth to you, but rather what that item would
be worth to a willing buyer. Cars should be valued by the N.A.D.A. Official Used Car Guide.

Real Property: When valuing real property, indicate the fair market value. Alternatively, use the
appraised tax value from your yearly property tax statement
                         DOCUMENTS NEEDED

Please bring the following documents to our office. It is very important that
you bring these items with you.

1.    Copies of any notes, Deeds of Trust and property tax statements on any
      real estate you own or are buying.

2.    Copies of any notes or retail installment contracts from banks, credit
      unions, finance companies or other lenders together with any security
      agreements or other documents itemizing the collateral where you are
      purchasing cars, furniture, mobile home, or other personal property.

3.    Current statements and bills.

4.    Tax returns for last 2 years.

5.    Pay stubs from all current employers for last six months.

6.    Proof of Insurance on all automobiles and real estate. Please attach the
      declaration page of the policies.

7.    All legal documents pertaining to divorces or lawsuits which are pending
      or which have been finalized in the past 12 months.

8.    Copies of all life insurance policies which have a cash value. You do
      not need to bring copies of any term life policies.

9.    All judgments.

10.   All executory contracts, i.e. leases, contracts for sale or deed and lease-
      purchase contracts.

11.   Bank statements for last 2 months.
                          Primary Debtor Information:
  Last Name:

  First Name:

  Middle Name:

List other names used in the                                    Enter all Social Security Numbers
last six (6) years:                                             and/or Tax ID Numbers:

  1.                                                       1.

  2                                                        2.

Street Address:                                                 Mailing Address (if different):




 County:                                                   County:

  Please circle one:

      Individual Filing                        Joint Filing (Husband and Wife)

What is the nature of your debts (1 = Non-business; 2 = Business)?

 Are you married? (Y/N):                      What Chapter are you filing?: 7 11 12 13
 (If married, please fill out spouse section on the next page even if your spouse is not
filing.)
Prior/related Bankruptcy:
Please indicate any bankruptcy filing within the last eight (8) years. Also indicate any pending bankruptcies
by a spouse or affiliate.

 Chapter     Court case was        Date case                             Debtor name as           Disposition
 Filed       filed in              was filed          Case Number        styled in case           of Case
                    Spouse/Joint Debtor Information:
       Last Name:

      First Name:

Middle Name:

 List other names used in the                      Enter all Social Security Numbers
 last six (6) years:                               and/or Tax ID Numbers:

  1.                                          1.

  2                                           2.

 Street Address:                                   Mailing Address (if different):




 County:                                      County:

Have you lived in this area for the past 180 days? (Y/N):

Have you taken any cash advances on any credit cards in the last 90 days? (Y/N):

 If yes, please provide the following information:

 Creditor name:                       Date taken:                      Amount:
 Creditor name:                       Date taken:                      Amount:
                               Dependents

 Name                                      Age    Relationship




Occupation
Enter your employer's name and address here. If you are filing a Chapter 13, make
sure this is the address for your payroll department.

                            DEBTOR                               SPOUSE
     Occupation

     Name

     How long?

     Address
                              Statement of Financial Affairs
  Each question should be answered. If the question does not apply to you, please indicated by writing "NONE" in the space
provided. If you require additional space to answer any of the questions, please write on the back of the sheet or attach an additional
sheet.

  The information on this statement is very important and must be filled out completely. Failure to disclose any information could
result in your case being dismissed or contested.

  Questions # 16-21 apply only if you are currently engaged in the operation of a business.




1.        Income from employment or operation of business. State the gross amount of
          income you have received from employment or from the operation of your business from the
          beginning of this calendar year to this date. State also the gross amount of your income during the
          two (2) years immediately proceeding this calendar year. If this is a joint petition, state income from
          each spouse separately. (Married debtors filing under Chapter 13 must state income of both
          spouses whether a joint petition is filed, unless the spouses are separated and a joint petition is not
          filed). (Gross income is the amount you earned before any deductions are made for taxes,
          insurance, cost of goods sold, business expenses, etc...)

                                                   Regular (W-2) Employment

                                                          DEBTOR                                              SPOUSE
                         YEAR

                         2010             AMOUNT                                            AMOUNT
                     (January to
                       Present)

                                          SOURCE                                            SOURCE


                         2009             AMOUNT                                            AMOUNT


                                          SOURCE                                            SOURCE


                         2008             AMOUNT                                            AMOUNT


                                          SOURCE                                            SOURCE
2.    Income from other sources. State the amount of income you have received from any other
      source besides employment or regular operation of your business. For example, please indicate
      income from social security, pensions, unemployment benefits, interest income from bank accounts
      or retirement distributions.


                                                     DEBTOR                                     SPOUSE
                                   AMOUNT                               AMOUNT
            2010
            (January to Present)

                                   SOURCE                               SOURCE



                                   AMOUNT                               AMOUNT
            2009

                                   SOURCE                               SOURCE



                                   AMOUNT                               AMOUNT
            2008

                                   SOURCE                               SOURCE




3.    Payment of loans, installment purchases and other debts.
 A.   List all payments on loans, installment purchases of goods or services, and other debts,
      aggregating more than $600 to any creditor, made within 90 days immediately preceding the
      commencement of this case. (Married debtors filing separately must disclose information about a
      spouse if this is a Chapter 13 or Chapter 12 case). Example: Car or mortgage payment of more
      than $200.00 per month.


                            NAME AND ADDRESS OF CREDITOR                  DATE         AMOUNT        BALANCE

            1.



            2.




 B.   List all payments made within the last year to or for the benefit of any creditor who was an insider.
      For example, insiders are your relatives, partners and their relatives and corporations you control
      and their affiliates. (Married debtors filing separately must disclose information about a spouse if
      this is a Chapter 13 or Chapter 12 case).


                            NAME AND ADDRESS OF CREDITOR                  DATE         AMOUNT        BALANCE

            1.
4.      Suits, executions, garnishments and attachments.

 A.     List all lawsuits you have been a party to in the last year. Please include information on any divorce
        proceedings, personal injury actions or suit involving the collection of debts. (Married debtors filing
        separately must disclose information about a spouse if this is a Chapter 13 or Chapter 12 case).


                    CAPTION AND CAUSE NUMBER             NATURE OF SUIT             COURT           CURRENT STATUS

               1.



               2.




 B.     Describe all property that has been attached, garnished or seized under any legal or equitable
        process within the last year. (Married debtors filing separately must disclose information about a
        spouse if this is a Chapter 13 or Chapter 12 case).


                 NAME/ADDRESS OF PARTY SEIZING              DATE         PROPERTY SEIZED       VALUE OF PROPERTY

               1.



               2.




5.       Repossessions, foreclosures and returns. List all property that has been repossessed
by a creditor, foreclosed upon, transferred in lieu of foreclosure or returned to the creditor voluntarily within
the last year. For example, include any automobiles that were repossessed by a creditor or returned
voluntarily to a creditor. Also include any real property that has already been foreclosed.


                    NAME/ADDRESS OF CREDITOR                DATE         PROPERTY DESC.        VALUE OF PROPERTY

               1.




               2.




6.      Assignments and receiverships.
 A.     Describe any assignment of property that you have made for the benefit of a creditor within the last
        120 days. (Married debtors filing separately must disclose information about a spouse if this is a
        Chapter 13 or Chapter 12 case).


                    NAME/ADDRESS OF CREDITOR                DATE          TERMS/VALUE OF ASSIGNMENT AGREEMENT

               1.




 B.     List all property which has been in the hand of a custodian, receiver, or court-appointed official
     within the last year. For example, list anyone who has been assigned by a court to administer your
     affairs with respect to a piece of property.


                NAME/ADDRESS OF CUSTODIAN              DATE         CASE TITLE/COURT        DESC. & VALUE OF
                                                                   LOCATION                PROPERTY

           1.




7.   Gifts and charitable donations. List all gifts or charitable contributions made within one
     year immediately preceding the commencement of this case except ordinary and usual gifts to
     family members aggregating less than $200 in value per family member and charitable contributions
     aggregating less than $100 per recipient.


           NAME/ADDRESS OF PERSON                  DATE           DESCRIPTION & VALUE            RELATIONSHIP
           OR ORGANIZATION




8.   Losses. List all losses from fire, theft, other casualty or gambling within one year immediately
     proceeding the commencement of this case or since the commencement of this case.


                DESCRIPTION OF PROPERTY          VALUE          % COVERED BY            DESCRIPTION OF
                                                              INSURANCE            CIRCUMSTANCES

           1.



           2.




9.   Payments or transfers to attorneys. List all payments you made or property you
     transferred, or which was transferred on your behalf, to anyone, including attorneys, for consultation
     concerning debt consolidation, relief under the bankruptcy law or preparation of a petition in
     bankruptcy within one year immediately proceeding the commencement of this case.


           NAME/ADDRESS OF ATTORNEY                DATE OF             DESCRIPTION OF PAYMENT OR
                                                   PAYMENT             PROPERTY GIVEN

           1.
10.     Other transfers. List all other property, other than property transferred in the ordinary course of
        the business or financial affairs of the debtor, transferred either absolutely or as security within on
        year immediately preceding the commencement of this case.


                    NAME/ADDRESS OF RECEIVER                DATE                 DESCRIPTION OF PROPERTY
                        AND RELATIONSHIP                                          AND AMOUNT RECEIVED

               1.


               2.



11.      Closed financial accounts. List all financial accounts and instruments held in your name or
for your benefit which were closed, sold or otherwise transferred within the last year. Include checking and
savings accounts as well as certificates of deposit, share accounts held in banks and credit unions. Also
include any pension funds or brokerage accounts.


               FINANCIAL INSTITUTION (NAME AND ADDRESS)                    TYPE OF ACCOUNT

               1.

                                                                           ACCOUNT NUMBER



                                                                           DATE CLOSED                BALANCE




               FINANCIAL INSTITUTION (NAME AND ADDRESS)                    TYPE OF ACCOUNT

               2.

                                                                           ACCOUNT NUMBER



                                                                           DATE CLOSED                BALANCE




12.     Safe deposit boxes. List all safe deposit boxes or other depositories in which you have kept
        securities or other items within the last year. (Married debtors filing separately must disclose
        information about a spouse if this is a Chapter 13 or Chapter 12 case).


               FINANCIAL INSTITUTION (NAME AND ADDRESS)                    OTHERS WITH ACCESS TO THE BOX
                                                                           AND THEIR ADDRESS
               1.



                                                                           LIST CONTENTS OF THE BOX




13.     Setoffs. List all setoffs made by any creditor, including a bank, against a debt or deposit of the
        debtor within the last 90 days. For example, if a creditor took funds that he was holding for you in
        order to satisfy a liability to him, that creditor should be listed here.


                    NAME/ADDRESS OF CREDITOR                DATE OF SETOFF                   AMOUNT SETOFF

               1.
14.   Property held for another person. List all property that is currently in your possession that is
      owned by another person.

                 NAME/ADDRESS OF OWNER              DESCRIPTION AND VALUE OF       LOCATION OF PROPERTY
                                                    PROPERTY




15.   Prior addresses. List all addresses of your residence within the last 2 years proceeding this petition.

                                         ADDRESS                                     FROM            TO
                                                                                                Income
     Please list your future monthly income and that of your spouse (if applicable). As backup, please
   attach the latest paycheck stub for you and your spouse to this page. If you are self-employed or
   have a variable income, please PROJECT an average monthly income based on what you expect
   to make over the next 12 months.


 How often are you paid? (M = Monthly; B = Bi-Weekly*; S = Semi-Monthly*; W = Weekly                                                DEBTOR   SPOUSE
 * Bi-Weekly means every 2 weeks. Semi-Monthly means twice a month.


                                                                                                                           DEBTOR       SPOUSE

 Gross wages per period specified .............................................................................
 (Please enter gross wages per pay check here. For example, if you are paid weekly, enter the weekly amount here!)


 Overtime Wages per period ......................................................................................


 Deductions:
Payroll taxes and Social Security tax .....................................................................


Insurance deductions .............................................................................................


Union Dues ............................................................................................................


Other(specify) .........................................................................................................


 Income from other sources:
 Income from real property .........................................................................................


 Interest and dividends ...............................................................................................


 Alimony and support .................................................................................................


 Social Security or other government assistance .......................................................


 Pension or retirement income ...................................................................................




 TOTAL GROSS INCOME:                                                                                        TOTAL NET INCOME:
 (optional)                                                                                                (optional)
                                                        Estimated Monthly Budget
    Please project your future monthly expenses here. Remember, you are projecting to the
   court how much you think you will spend each month after your bankruptcy is filed. This
   means that those debts which are being discharged or paid through a plan of reorganization
   should not be included. Also remember that you may have to adjust your spending habits in
   order to have the necessary surplus to pay the Chapter 13 trustee.


Rent or house payment(s) .......................                    Insurance:

Taxes included? (Y/N) ..........................                   Homeowner's or renter's ....................


Insurance included? (Y/N) ....................                     Life .....................................................


                                                                   Health ................................................



Electric and heat...................................               Auto ...................................................


Water and sewer ..................................                 Other(specify):


Telephone ............................................             ..............


Other(specify) .......................................              Installment payments:

Home maintenance .................................                 Auto ...................................................


Food ........................................................


Clothing ...................................................       Other(specify):


Laundry and dry cleaning ........................                   Alimony, support ..................................


Medical and dental ..................................               Support of dependents
                                                                    not living at home ................................

Transportation .........................................            Regular business expenses ................


Recreation, reading .................................               Other(specify):


Charitable contributions...........................                 Other(specify):



  TOTAL EXPENSES (BUDGET):
  (optional)


  DISPOSABLE INCOME:
  (optional)
                                                             Creditors
   Please list all debts that you owe on this worksheet. If you have a copy of the billing statement, please attach it to the back of the page
 where the creditor is entered. You must schedule all your debts on this form in order for us to accurately complete your schedules. If you are
 unsure about how to fill out any of the questions you can call our office. The Chapter 13 and Chapter 7 part at the bottom of each creditor
 entry will be filled out by our office so do not check unless you are confident as to how that creditor is to be treated.

   If possible, list your secured debts and tax debts first then go on to list the unsecured creditors (credit cards) later.

 What is a secured debt? A secured debt is a debt which has collateral or security. This means that if you don't pay the debt, the
 creditor could come and repossess the item he is holding as security for the debt. Houses, land, cars, large appliances and furniture are all
 examples of secured debts.

 What is a priority debt? A priority debt is a tax or administrative debt. The Internal Revenue Service and other taxing authorities are
 the best examples of priority debt. However, there are many circumstances where the IRS could also be a secured or even an unsecured
 debt.

 What is an unsecured debt? Unsecured creditors do not have any collateral to secure payment of their debt. Examples of
 unsecured debt include most credit cards, medical bills, signature loans, and deficiencies that remain after a secured creditor repossesses
 and sells its collateral, if the proceeds from the sale do not pay off the debt. Purchases of appliances, furniture, televisions, VCR's, stereos,
 computers, jewelry and other tangible goods purchased on department store credit cards are secured debts. Those same items purchased
 on Visa, Master Card, American Express and Discover are unsecured.

 If you have a homestead, please list it and other real property first:

CREDITOR NAME & ADDRESS                                                                 AMOUNT OF CLAIM:          $




                                                                                        CONTRACT PAYMENT:         $
                                                                                        (if secured)

                                                                                        VALUE OF SECURITY:        $
                                                                                        (if secured)

ACCOUNT NUMBER:                                                                         IF DISPUTED, AMOUNT       $
                                                                                        ADMITTED:

DESCRIPTION OF DEBT:                                                                    NUMBER OF MONTHS IN
                                                                                        ARREARS:


                                                                                        [ ] PRIORITY                  [ ] SECURED

                                                                                        [ ] UNSECURED                 [ ] SPECIAL



CREDITOR NAME & ADDRESS                                                                 AMOUNT OF CLAIM:          $




                                                                                        CONTRACT PAYMENT:         $
                                                                                        (if secured)

                                                                                        VALUE OF SECURITY:        $
                                                                                        (if secured)

ACCOUNT NUMBER:                                                                         IF DISPUTED, AMOUNT       $
                                                                                        ADMITTED:

DESCRIPTION OF DEBT:                                                                    NUMBER OF MONTHS IN
                                                                                        ARREARS:


                                                                                        [ ] PRIORITY                  [ ] SECURED

                                                                                        [ ] UNSECURED                 [ ] SPECIAL
CREDITOR NAME & ADDRESS   AMOUNT OF CLAIM:      $




                          CONTRACT PAYMENT:     $
                          (if secured)

                          VALUE OF SECURITY:    $
                          (if secured)

ACCOUNT NUMBER:           IF DISPUTED, AMOUNT   $
                          ADMITTED:

DESCRIPTION OF DEBT:      NUMBER OF MONTHS IN
                          ARREARS:


                          [ ] PRIORITY              [ ] SECURED

                          [ ] UNSECURED             [ ] SPECIAL



CREDITOR NAME & ADDRESS   AMOUNT OF CLAIM:      $




                          CONTRACT PAYMENT:     $
                          (if secured)

                          VALUE OF SECURITY:    $
                          (if secured)

ACCOUNT NUMBER:           IF DISPUTED, AMOUNT   $
                          ADMITTED:

DESCRIPTION OF DEBT:      NUMBER OF MONTHS IN
                          ARREARS:


                          [ ] PRIORITY              [ ] SECURED

                          [ ] UNSECURED             [ ] SPECIAL



CREDITOR NAME & ADDRESS   AMOUNT OF CLAIM:      $




                          CONTRACT PAYMENT:     $
                          (if secured)

                          VALUE OF SECURITY:    $
                          (if secured)

ACCOUNT NUMBER:           IF DISPUTED, AMOUNT   $
                          ADMITTED:

DESCRIPTION OF DEBT:      NUMBER OF MONTHS IN
                          ARREARS:


                          [ ] PRIORITY              [ ] SECURED

                          [ ] UNSECURED             [ ] SPECIAL
CREDITOR NAME & ADDRESS   AMOUNT OF CLAIM:      $




                          CONTRACT PAYMENT:     $
                          (if secured)

                          VALUE OF SECURITY:    $
                          (if secured)

ACCOUNT NUMBER:           IF DISPUTED, AMOUNT   $
                          ADMITTED:

DESCRIPTION OF DEBT:      NUMBER OF MONTHS IN
                          ARREARS:


                          [ ] PRIORITY              [ ] SECURED

                          [ ] UNSECURED             [ ] SPECIAL



CREDITOR NAME & ADDRESS   AMOUNT OF CLAIM:      $




                          CONTRACT PAYMENT:     $
                          (if secured)

                          VALUE OF SECURITY:    $
                          (if secured)

ACCOUNT NUMBER:           IF DISPUTED, AMOUNT   $
                          ADMITTED:

DESCRIPTION OF DEBT:      NUMBER OF MONTHS IN
                          ARREARS:


                          [ ] PRIORITY              [ ] SECURED

                          [ ] UNSECURED             [ ] SPECIAL



CREDITOR NAME & ADDRESS   AMOUNT OF CLAIM:      $




                          CONTRACT PAYMENT:     $
                          (if secured)

                          VALUE OF SECURITY:    $
                          (if secured)

ACCOUNT NUMBER:           IF DISPUTED, AMOUNT   $
                          ADMITTED:

DESCRIPTION OF DEBT:      NUMBER OF MONTHS IN
                          ARREARS:


                          [ ] PRIORITY              [ ] SECURED

                          [ ] UNSECURED             [ ] SPECIAL
CREDITOR NAME & ADDRESS               AMOUNT OF CLAIM:      $




                                      CONTRACT PAYMENT:     $
                                      (if secured)

                                      VALUE OF SECURITY:    $
                                      (if secured)

ACCOUNT NUMBER:                       IF DISPUTED, AMOUNT   $
                                      ADMITTED:

DESCRIPTION OF DEBT:                  NUMBER OF MONTHS IN
                                      ARREARS:


                                      [ ] PRIORITY              [ ] SECURED

                                      [ ] UNSECURED             [ ] SPECIAL



CREDITOR NAME & ADDRESS               AMOUNT OF CLAIM:      $




                                      CONTRACT PAYMENT:     $
                                      (if secured)

                                      VALUE OF SECURITY:    $
                                      (if secured)

ACCOUNT NUMBER:                       IF DISPUTED, AMOUNT   $
                                      ADMITTED:

DESCRIPTION OF DEBT:                  NUMBER OF MONTHS IN
                                      ARREARS:


                                      [ ] PRIORITY              [ ] SECURED

                                      [ ] UNSECURED             [ ] SPECIAL



CREDITOR NAME & ADDRESS               AMOUNT OF CLAIM:      $




                                      CONTRACT PAYMENT:     $
                                      (if secured)

                                      VALUE OF SECURITY:    $
                                      (if secured)

ACCOUNT NUMBER:                       IF DISPUTED, AMOUNT   $
                                      ADMITTED:

DESCRIPTION OF DEBT:                  NUMBER OF MONTHS IN
                                      ARREARS:


                                      [ ] PRIORITY              [ ] SECURED

                                      [ ] UNSECURED             [ ] SPECIAL



 ADD ADDITIONAL SHEETS AS NECESSARY
  Leases and contracts:
Yes/No     Question

           Do you have any unexpired leases or executory contracts of any kind? Include any
           and all apartment leases, house leases, car leases, etc., all rental agreements,
           contracts for deed, contracts for sale. If yes, please list all parties to the contract
           and/or lease, describe the nature of the interest and attach copies of the lease
           and/or contract to this package. Also, please indicate whether you wish to
           assume (keep) or reject the contract/lease.

DESCRIPTION (Type of       NAME AND ADDRESS OF PARTY   NAME AND ADDRESS OF PARTY   NAME AND ADDRESS OF PARTY
contract/lease):           ON CONTRACT/LEASE:          ON CONTRACT/LEASE           ON CONTRACT/LEASE




ASSUME? (Y/N):
                                                   Real Property Assets
  What is real property? Real property consists of land and whatever is erected or growing upon or affixed to
  the land. What does this mean to you? It means your home, any rental property or acreage.

  What is a homestead? A homestead is your land (with or without a dwelling) and the adjoining land where
  the head of a family dwells. It is your fixed residence with the land and buildings surrounding the main house. In
  other words, if you own a house and/or land, and it is your primary place of residence, this land/house can be
  claimed as your homestead. I

  Please list the property you claim as your homestead here:
ADDRESS OF HOMESTEAD:                                                       AMOUNT OWED: $




                                                                            MARKET VALUE: $

                                                                            MONTHLY PMTS: $



LEGAL DESCRIPTION OF HOMESTEAD:                                             TYPE OF LOAN (VA, FHA OR CONVENTIONAL):




                                                                            LIENHOLDER NAME:



                                                                            LIENHOLDER PHONE:




  If you are in arrears on the payments on your homestead, please fill out the section below:
  (You should list the arrearage amount as a separate creditor in the "Creditors" section of this
  package if you are filing a Chapter 13)

NO OF MONTHS IN ARREARS:                             LATE FEES: $                                  TOTAL ARREARAGE AMT: $



PLEASE LIST SPECIFIC MONTHS NOT PAID:




  Second Lien (if any):
 CREDITOR NAME & ADDRESS: (Be sure and list name and address with secured   AMOUNT OWED: $
creditors as well)




                                                                            MARKET VALUE: $

                                                                            MONTHLY PAYMENTS: $

LIST MONTHS NOT PAID:
  Other Real Property:
ADDRESS OF PROPERTY:                                   AMOUNT OWED: $
(1)




                                                       MARKET VALUE: $



                                                       MONTHLY PMTS: $



LEGAL DESCRIPTION:                                     TYPE OF LOAN (VA, FHA OR CONVENTIONAL):




                                                       LIENHOLDER NAME:



                                                       LIENHOLDER PHONE:




  If you are in arrears on the payments on this property, please fill out the section below:

NO OF MONTHS IN ARREARS:                LATE FEES: $                          TOTAL ARREARAGE AMT: $



PLEASE LIST SPECIFIC MONTHS NOT PAID:
                                       Personal Property Assets
Cat
                                                                                     H,W,J,C   Value
               Cash on hand

     1          Enter amount of cash on hand.

Cat
               Cash on deposit                                                                         H,W,J,C


     2        List cash on deposit. Please list all current bank accounts, certificates of
              deposit, shares in bank accounts or credit unions, money market accounts or
              any other institutions with which you have a deposit. All bank accounts must be
              listed, including inactive accounts where the balance is very small.
FINANCIAL INSTITUTION (NAME AND ADDRESS)        TYPE OF ACCOUNT                    NAME ON ACCOUNT

1.


                                                ACCOUNT NUMBER                     BALANCE




                                                WHO ELSE CAN SIGN ON ACCOUNT (AND THEIR ADDRESS)?




FINANCIAL INSTITUTION (NAME AND ADDRESS)        TYPE OF ACCOUNT                   NAME ON ACCOUNT

2.


                                                ACCOUNT NUMBER                    BALANCE




                                                WHO ELSE CAN SIGN ON ACCOUNT (AND THEIR ADDRESS)?




Cat
                                                                                                       H,W,J,C
         Security deposits

     3 List all security deposits with public utilities, telephone companies, landlords or
       others.
NAME AND ADDRESS OF CREDITOR                                AMOUNT OF DEPOSIT      ACCOUNT NUMBER
1.

2.

3.
Cat
           HOUSEHOLD GOODS AND FURNISHINGS    (Garage Sale Value)

   4 Complete this form by indicating the number of items (QTY) you own in the space provided
     and the value. If no item of that description is owned, leave blank. Write in other items you
     own under "other" in each category. In assessing the value of an item, use the value that
     you could receive in a sale to a third party (i.e, GARAGE SALE VALUE). Be sure to
     schedule all lien holders on schedules. Please note whether the asset is owned by the
     Husband (H), Wife (W), as Community property (C), or as Joint property (J).

                                              HOUSEHOLD GOODS

  LIVING ROOM:                                 KITCHEN AND DINING ROOM

ITEM                  QTY   H,W,C,J   VALUE         ITEM                   QTY   H,W,C,J   VALUE

Sofa                                                Stove

Sectional Sofa                                      Refrigerator

Recliner                                            Dishwasher

Love Seat                                           Trash Compactor

Side Chair                                          Microwave Oven

Coffee Table                                        Small Appliances

End Table                                           Pots and Pans

Bookcase                                            Dishes and Glassware

Compact Disc Player                                 Flatware

Color Television                                    Sterling ware

B/W Television                                      China

Stereo                                              Crystal

Stereo Cabinet                                      Table and Chairs

Lamp                                                China Cabinet

Computer                                            Buffet

VCR                                                 Other:

Other:
Cat         Books pictures and other art objects

   5       List any books; pictures or other art objects; stamp coin, record, tape, CD or other
           collections. Please describe and give the value as well as note whether the asset is
           owned by the Husband (H), Wife (W), as Community property (C), or as Joint
           property (J).
ITEM DESCRIPTION                                                           QTY       H,W,C,J         VALUE




Cat        Clothing

      6    Please supply the VALUE of your wearing apparel

Cat        Furs and jewelry


      7    List all furs or jewelry. Please complete the following and note whether the
            asset is owned by the Husband (H), Wife (W), as Community property (C), or as
           Joint property (J):

ITEM                  QTY     H,W,C,J    VALUE              ITEM                 QTY       H,W,C,J           VALUE

Watch                                                       Watch

Wedding Ring                                                Wedding Ring

Chain                                                       Necklace

Rings                                                       Earrings

Furs                                                        Bracelets

Other(specify):                                             Rings

                                                            Furs

Cat         Firearms, sports equipment, photographic equipment and hobby equipment

      8    List all firearms, sports equipment, photographic equipment or other hobby
           equipment. Please describe the items, give the value...

ITEM DESCRIPTION                                                           QTY       H,W,C,J     VALUE
Cat       Cash value of life insurance



     9    List all insurance policies that have any cash surrender or refund value. Include
          the name and address of any lienholder as indicated below. Often, the insurance
          company itself will loan you money against their own policy. Be sure and list the
          lienholder as a secured creditor. Please complete the following information and note
          whether the asset is owned by the Husband (H), Wife (W), as Community property
          (C), or as Joint property (J):
INSURANCE COMPANY:                       POLICY NUMBER:                  H,W,C,J
1.


2.

                                         BENEFICIARY:
3.

                                         VALUE:                          DATE ACQUIRED:

IF THERE IS A LIENHOLDER, PLEASE GIVE THEIR NAME, ADDRESS AND THE AMOUNT OF THE LIEN:




Cat       Annuities

     10   List all annuities. Please complete the following information and note whether the
          asset is owned by the Husband (H), Wife (W), as Community property (C), or as Joint
          property (J):
ISSUER'S NAME AND ADDRESS:                    DOCUMENT NUMBER:                                      H,W,C,J




                                              PAYMENT SCHEDULE:




IF THERE IS A LIENHOLDER, PLEASE GIVE THEIR NAME, ADDRESS AND THE AMOUNT OF THE LIEN:




AMOUNT OF LIEN:

Cat
          Retirement, IRA's, 401 K Plans and other pensions

          List any interest of any kind in an IRA, company retirement account, KEOGH Plan,
     11   ESOP Plan, profit sharing Plan or any other type of pension or retirement plan.
          Please complete the following information and note whether the asset is owned by
          the Husband (H), Wife (W), as Community property (C), or as Joint property (J):
DESCRIPTION:                                                  MARKET VALUE:               H,W,C,J
(A.)




IF THERE IS A LIENHOLDER, PLEASE GIVE THEIR NAME, ADDRESS AND THE AMOUNT OF THE LIEN:
AMOUNT OF LIEN:

Cat       Stocks or interests in corporations



   12    List any stock or interests in incorporated or unincorporated companies. Please
         complete the following information and note whether the asset is owned by the
         Husband (H), Wife (W), as Community property (C), or as Joint property (J):
NAME OF COMPANY:                                 NUMBER OF SHARES:       NAME ON SHARES:       VALUE OF SHARES:        H,W,C,J




Cat     Interests in partnerships


13      List any interest in partnerships. Please complete the following information and note
        whether the asset is owned by the Husband (H), Wife (W), as Community property (C),
        or as Joint property (J):
NAME OF PARTNERSHIP:                               NATURE OF INTEREST:                      VALUE OF INTEREST:         H,W,C,J




                                                                                            PERCENT OF INTEREST:




Cat      Government or corporate bonds - negotiable instruments



 14     List any government or corporate bonds or other negotiable or non-negotiable
        instruments. Please complete the following information and note whether the asset is
        owned by the Husband (H), Wife (W), as Community property (C), or as Joint property
        (J):
DESCRIPTION:                                                                MARKET VALUE:                              H,W,C,J




IF THERE IS A LIENHOLDER, PLEASE GIVE THEIR NAME, ADDRESS AND THE AMOUNT OF THE LIEN:




AMOUNT OF LIEN:

Cat     Accounts receivable


15      List any accounts receivable. Please complete the following information and note
        whether the asset is owned by the Husband (H), Wife (W), as Community property (C),
        or as Joint property (J):
(A.) NAME OF DEBTOR:                                                        AMOUNT OWED:                    H,W,C,J:

ADDRESS OF DEBTOR:                                                          PROBABLE COLLECTION? (Y/N):




IF THERE IS A LIENHOLDER, PLEASE GIVE THEIR NAME, ADDRESS AND THE AMOUNT OF THE LIEN:




AMOUNT OF LIEN:
Cat
          Alimony, maintenance, support or property settlements

16       List any alimony, maintenance, support or property settlements. Please complete the
         following information and note whether the asset is owned by the Husband (H), Wife (W),
         as Community property (C), or as Joint property (J):
NAME OF DEBTOR:                    DESCRIPTION OF INTEREST:                          TOTAL AMOUNT OWED:          H,W,C,J:
(Person owing the money)

                                                                                     MONTHLY AMOUNT OWED:        DATES PAYMENT DUE:


Cat       Liquidated debts

17       List any liquidated debts (a debt owing in a specific amount) owed to you that have not been previously
         listed. Please complete the following information and note whether the asset is owned by the Husband (H),
         Wife (W), as Community property (C), or as Joint property (J):
NATURE OF DEBT:                                                                           AMOUNT OWED:                      H,W,C,J:

NAME AND ADDRESS OF DEBTOR:                                                               DATE OF COLLECTION:


                                                                                          PROBABILITY OF COLLECTION?:


IF THERE IS A LIENHOLDER, PLEASE GIVE THEIR NAME, ADDRESS AND THE AMOUNT OF THE LIEN:




AMOUNT OF LIEN:


Yes/No          Question

                Are you expecting a tax refund? If yes, please complete the following information and
                note whether the asset is owned by the Husband (H), Wife (W), as Community
                property (C), or as Joint property (J):
TAX YEAR 1:                                 AMOUNT EXPECTED:                             DATE EXPECTED:                           H,W,C,J:




          Equitable or future interests, life estates or rights or powers


18       List any equitable or future interests, life estates or rights or powers in anything not
         previously listed. Please describe the interest and note whether the asset is owned by the
         Husband (H), Wife (W), as Community property (C), or as Joint property (J):
DESCRIPTION:                                                                MARKET VALUE OF INTEREST:               H,W,C,J:




Cat      Contingent, non-contingent and/or unliquidated interests in estates, life insurance or trusts

19      List any contingent, non-contingent, and/or unliquidated interests in an estate of a
        decedent, death benefit plan, life insurance policy or trust. Please describe, in detail, the
        interest and note whether the asset is owned by the Husband (H), Wife (W), as Community
        property (C), or as Joint property (J):
DESCRIPTION:                                                                MARKET VALUE OF INTEREST:               H,W,C,J:
Cat
            Contingent and or unliquidated claims

20         List any other contingent and/or unliquidated claims, including any other counterclaims,
           or rights to setoff claims? If yes, please describe and note whether the asset is owned by
           the Husband (H), Wife (W), as Community property (C), or as Joint property (J):
DESCRIPTION:                                                       MARKET VALUE OF INTEREST:                      H,W,C,J:




Cat
            Patents, copyrights or other intellectual property

21         List any patents, copyrights, or other intellectual property. Please describe and note
           whether the asset is owned by the Husband (H), Wife (W), as Community property (C), or as
           Joint property (J):
DESCRIPTION:                                                     MARKET VALUE:          SUBSTANTIATING DOCUMENTS:             H,W,C,J:




Cat
            Licenses, franchises or other intangibles

22         List any licenses, franchises, or other intangibles. Please describe and note whether
           the asset is owned by the Husband (H), Wife (W), as Community property (C), or as Joint
           property (J):
DESCRIPTION:                                                                                                    H,W,C,J:




Cat
            Automobiles, trucks, trailers, mobile homes and other vehicles

23         Please list all automobiles, trucks, trailers, mobile homes and other vehicles and note
           whether the asset is owned by the Husband (H), Wife (W), as Community property (C), or as
           Joint property (J).
           ** If you own more than three vehicles, attach additional paper and provide the same
           information requested below.
YEAR OF VEHICLE:         MAKE OF VEHICLE:                             MODEL OF VEHICLE (LS, GT, etc.):                       H,W,J,C:
(1.)


DATE OF PURCHASE:

NAME OF LIENHOLDER AND PHONE NUMBER:                                  PAYOFF WITHOUT INTEREST:           BLUE BOOK VALUE:

(      )

YEAR OF VEHICLE:           MAKE OF VEHICLE:                          MODEL OF VEHICLE (LS, GT, etc.):                         H,W,J,C:
(2.)


DATE OF PURCHASE:

NAME OF LIENHOLDER AND PHONE NUMBER:                                 PAYOFF WITHOUT INTEREST:             BLUE BOOK VALUE:


(      )

YEAR OF VEHICLE:         MAKE OF VEHICLE:                             MODEL OF VEHICLE (LS, GT, etc.):                       H,W,J,C:
(3.)
DATE OF PURCHASE:

NAME OF LIENHOLDER AND PHONE NUMBER:                                     PAYOFF WITHOUT INTEREST:      BLUE BOOK VALUE:


(       )

    *** PLEASE NOTE: Be sure to list all lien holders as creditors on the schedule of debts.


Cat
                 Boats, motors and their accessories

24              List any boats, motors, and their accessories. Please complete the following and note
                whether the asset is owned by the Husband (H), Wife (W), as Community property (C), or as
                Joint property (J).
    DESCRIPTION:                                                                   DATE OF PURCHASE:                      H,W,J,C:




Cat             Airplanes and their accessories



25              List any airplanes and their accessories. Please complete the following and note whether
                the asset is owned by the Husband (H), Wife (W), as Community property (C), or as Joint
                property (J).
    DESCRIPTION:                                                                   DATE OF PURCHASE:                      H,W,J,C:




    NAME OF LIENHOLDER AND PHONE NUMBER:                                           MARKET VALUE:


    (       )


                 Office equipment, furnishings and supplies



26              List office equipment, furnishings and supplies. Do not include desks, etc. used at home.
                Please attach an itemized list and complete the following noting whether the asset is owned by the Husband
                (H), Wife (W), as Community property (C), or as Joint property (J).
DESCRIPTION:                                                                       H,W,J,C:




                                                                                   MARKET VALUE:




Cat
                Tools of trade, machinery, fixtures, equipment/supplies used in business


27              List any tools of trade, machinery, fixtures, equipment, or supplies used in business not
                previously listed. Please attach an itemized list and complete the following noting whether
                the asset is owned by the Husband (H), Wife (W), as Community property (C), or as Joint
                property (J).
DESCRIPTION:                                                                       H,W,J,C:


NAME OF LIENHOLDER AND PHONE NUMBER:                                               MARKET VALUE:

(       )
Cat
            Inventory

28         List all inventory. Please attach an itemized list and complete the following noting
           whether the asset is owned by the Husband (H), Wife (W), as Community property (C), or as
           Joint property (J).
DESCRIPTION:                                                      H,W,J,C:




NAME OF LIENHOLDER AND PHONE NUMBER:                              MARKET VALUE:


(      )

Cat
            Animals

29         List all animals including but not limited to horses, cows, pigs, chickens, dogs, cats, birds,
           fish and any household pets. If yes, please complete the following and note whether the
           asset is owned by the Husband (H), Wife (W), as Community property (C), or as Joint
           property (J).
    DESCRIPTION:                                                                                     H,W,J,C:


Cat
            Crops

30         List any crops. Please complete the following and note whether the asset is owned by the Husband (H),
           Wife (W), as Community property (C), or as Joint property (J).

DESCRIPTION:                                                                                         H,W,J,C:




Cat
            Farming supplies or implements

31         List any farming supplies or implements. Please complete the following and note
           whether the asset is owned by the Husband (H), Wife (W), as Community property (C), or as
           Joint property (J).
DESCRIPTION:                                                                                         H,W,J,C:




Cat
            Farming supplies, chemicals and feeds

32         List any farming supplies, chemicals or feeds. Please complete the following and note
           whether the asset is owned by the Husband (H), Wife (W), as Community property (C), or as
           Joint property (J).
DESCRIPTION:                                                      H,W,J,C:




NAME OF LIENHOLDER AND PHONE NUMBER:                              MARKET VALUE:


(      )
Cat       Other personal property


33        List other personal property of any kind not previously scheduled. Please describe the nature of the
          property and complete the following noting whether the property is owned by the Husband (H), Wife (W), as
          Community property (C), or as Joint property (J).
DESCRIPTION:                                                        H,W,J,C:




NAME OF LIENHOLDER AND PHONE NUMBER:                                MARKET VALUE:

(     )
                                         Co-Debtors
Yes/No    Question

          Do you have any debts which have been co-signed with parties other than you or
          your spouse (if this is a joint filing)? If yes, please complete the following
          information:

NAME AND ADDRESS OF CO-DEBTOR:                 NAME AND ADDRESS OF CREDITOR:

				
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