RICHARD A. SCHWARTZ, ATTORNEY Louisville, Kentucky Office 3339 Taylorsville Road Louisville, KY 40205 Telephone: (502) 485-9200 Fax: (502) 485-9220 New Albany, Indiana Office 810 East Market Street New Albany, IN 47150 Telephone: (812) 945-9200 Fax: (502) 485-9220 BANKRUPTCY QUESTIONNAIRE Please complete all data requested in the form below. If not applicable, enter N/A. Date: Name: Spouse’s Name: Address: City: Phone Number: E-mail Address: State Zip code Number of Minor Children at Home: Total Gross Annual Household Income (per your last tax return): Self Employed? Yes No In order for us to give you advice as to whether or not you qualify to file Chapter 7 or 13, we need to know what property you own and who your creditors are. We also need to know your income and household expenses. ASSETS THAT YOU OWN 1. Do you own Real Estate? Yes No Value of your Real Estate? 1st Mortgage Balance Monthly Payment Arrearage? 2nd Mortgage Balance Monthly Payment Arrearage? $ $ $ $ $ $ $ 2. Auto Owned? Yes No Year/Make/Model Auto Value $ Date of Purchase: Amount Owed: $ 3. DEBTS Aside from home mortgages and car loans, do you owe any of the following? If yes, state the amount owed. If you do not know the exact amount owed, estimate the amount owed. Total Amount of Credit Card Debt: Total Amount of Medical Debt: Student Loan Debt Signature Loan Debt Other ( Please Specify) 4. TAXES Amount of your Last Tax Refund $ : $ $ $ $ $ Taxes Owed? Amount $ Yes No What year? 5. YOUR INCOME Gross Pay $ How often do you get paid? Weekly SPOUSE INCOME Gross Pay $ How often does your Spouse get paid? Weekly Bi-weekly Monthly Yearly Net Pay $ Bi-weekly Monthly Yearly Net Pay $ 6. MONTHLY LIVING EXPENSES Please complete the table below and total your monthly living expenses. Rent or Mortgage Payment Gas and Electric Water & Sewage Medical Expenses Auto Insurance $ $ $ $ $ Home Owners Insurance (if not escrowed) $ Property Taxes (if not escrowed) Auto Payments(s) Gas for Autos Alimony or Child Support Groceries Child Care Expenses Cable TV/Satellite Other expenses not listed above TOTAL MONTHLY EXPENSES $ $ $ $ $ $ $ $ $ PLEASE SAVE THIS FORM TO YOUR COMPUTER, AND E-MAIL THE COMPLETED FORM AS AN ATTACHMENT TO email@example.com (OR YOU MAY PRINT AND FAX THE FORM TO (502) 485-9220), SO THAT WE CAN GIVE YOU THE ADVICE YOU NEED REGARDING YOUR FINANCIAL SITUATION. This website form is designed for general information only. The information presented on this form should not be construed to be the formation of a lawyer/client relationship.