Premier Bankruptcy Specialists, LLC.
Client Questionnaire Form
Providing the complete names and addresses for every debt you owe (as well as the address of any company collecting for a respective debt [if applicable] is extremely important). Without this crucial information, the creditors you owe money cannot be notified by the court and the debt may not be eligible for discharge. In other words, you may have to pay the bill simply because you did not provide the court with an address to mail a notice that you filed bankruptcy – which then would not allow that company an opportunity to respond.
Credit Briefing Required. Congress has determined that individuals seeking relief under bankruptcy law must submit
to a credit briefing within 180 days prior to the filing of their case, unless circumstances do not allow. This briefing can be accomplished in person, over the telephone or the internet. You must obtain a certificate from an authorized credit counseling entity and file such certificate with the court when you file your petition. Our office will provide you with contact information for an unaffiliated credit counseling company, but we do not provide the service.
Other Areas to Pay Attention to on Debt Sheets:
Do not abbreviate. 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: www.usps.com. Make sure all the information for each creditor is completely filled in. Make sure to list the last collection agency’s address. That is to say the company that took over your “original” creditor/account. 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 particular charge account. In the area where your last six months gross income is requested be sure to list your income from employment, by each individual month. This information is required and not including it will delay finishing your petition.
Income Page
An often overlooked piece of vital information we need is your year-to-date income. The court also requires your income for 2005 and 2006. Your year-to-date income should appear on your recent paycheck stub. If you have had more than one employer this year, you must to provide us with the TOTAL amount of income you made for ALL employers. Please provide a copy of your most recent paycheck stub from each of your employers. If you also receive (or have received) another type of income, such as, (child support, unemployment, social security, pension, etc.), within the past 2 years, please list on income page.
1
Pay Stubs
Congress has determined that individuals seeking relief under bankruptcy law should file, with the court, a copy of evidence of all income received during the sixty (60) days prior filing the case. You should provide this information together with the evidence of your monthly income for each of the six (6) months prior to the case filing.
Tax Returns Mandatory
The Debtor must provide, to the court, a copy of their last tax return or a transcript at least 7 days before the meeting of creditors or the case “shall” be dismissed. The same tax information must also be provided to any creditor who requests it. The debtor must file all returns from 4 years prior to the Chapter13 filing. If you need some time to get current on your filings, the BK Court can postpone the proceedings.
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 collection, etc. – please list. You may find it easier to simply make a copy of the court documents and include it with your Client Questionnaire Forms. (We return all original court documents you send to us with you petition.)
Means Test
Congress has determined that individuals seeking relief under bankruptcy law should submit to a test of their income to allow the court to determine whether they are eligible for relief under chapter 7 or should proceed with a repayment plan under chapter 13. We require that you provide accurate records of your income and expenses.
Exemption Limitation Congress has determined that individuals seeking relief under bankruptcy law may be limited
in some cases to claim a homestead exemption in the event that the equity (amount that value exceeds mortgage and tax debt) in a home exceeds $125,000 in the event that the home was acquired within 3 ½ years prior to the filing of the case. We will examine this issue.
Summary
Thank you for taking the time to review the Client Questionnaire Forms before sending them to us. You will find that your efforts will save you a lot of time and money in long distance calls, which results in the delay of the processing of your bankruptcy petition. Please be sure ALL questions are answered. If a question does not pertain to your situation put “none”. Do not leave any questions unanswered. This questionnaire is being used to fill out the petition on your behalf. Please do not hesitate to email or call us if you have any questions whatsoever concerning our Client Questionnaire Forms. Thank you for choosing Premier Bankruptcy Specialists, LLC. in assisting you in this process. We sincerely want you to be happy and recommend us to others.
2
BANKRUPTCY WORKSHEET
Your full name _____________________________________ DOB: ______________
List all names you have used in the last 6 years, including assumed business names
Your Social Security Number __________________________ Full name of spouse (only if spouse is filing a joint petition with you)____________________________________________ DOB: _______________ List all names spouse has used in the last 6 years, including assumed business names_________________________________________________________________ Spouse's Social Security Number _______________________ Your current address (include city, state, zip, and COUNTY) _____________________________________________________________________________
List your complete mailing address, if it is different than your street address _________________________________________________________ Your day time phone number __________________Evening phone number________________ EMAIL address: ______________________________________________________________
REAL ESTATE
List ALL real property in which you have an interest, including property you own or are buying, property owned as a co-tenant, community property, or property in which you have a life estate. Property address____________________________________________________________________________ What is the current market value of this property?__________________________________________________ Are you current with your mortgage? ________________ If no, what is the total arrears? ___________________ Do you intend to keep this property and continue payments?___________ Do you claim your equity as exempt? ______
3
PERSONAL PROPERTY OWNERSHIP
List all personal property, of whatever kind below. If you have no property in one or more categories put "none". Do not list leased property in this section. If property you own is being held for you by someone else, list that person's name and address under Description and Location of property.
TYPE OF PROPERTY 1. CASH ON HAND DESCRIPTION/LOCATION CURRENT MARKET VALUE
2. CHECKING, SAVINGS, OR OTHER FINANCIAL ACCTS. CD'S, OR SHARES IN BANKS, SAVINGS AND LOAN, THRIFT, BUILDING AND LOAN, AND HOMESTEAD ASSOC. OR CREDIT UNIONS, BROKERAGE HOUSES OR COOPERATIVES. 3. SECURITY DEPOSITS WITH PUBLIC UTILITIES, TELEPHONE COMPANIES, LANDLORDS AND OTHERS 4. HOUSEHOLD GOODS AND FURNISHINGS, INCLUDING AUDIO, VIDEO AND COMPUTER EQUIPMENT. 5. BOOKS, PICTURES, AND OTHER ART OBJECTS, ANTIQUES, STAMP AND COIN COLLECTIONS OR COLLECTIBLES, RECORDS, TAPES, CD’S. 6. WEARING APPAREL 7. FURS AND JEWELRY 8. FIREARMS AND SPORTS, PHOTOGRAPHIC, AND OTHER HOBBY EQUIPMENT 9. INTEREST IN INSURANCE POLICIES. NAME INSURANCE COMPANY OF EACH POLICY AND ITEMIZE SURRENDER OR REFUND VALUE OF EACH. 10. ANNUITIES. ITEMIZE AND NAME EACH ISSUER. 11. INTERESTS IN AN EDUCATION IRA DEFINED IN 26 U.S.C. § 530(b)(1) OR UNDER A QUALIFIED STATE TUITION PLAN AS DEFINED IN 26 U.S.C. § 529(b)(1) GIVE PARTICULARS.
4
TYPE OF PROPERTY 12. INTERESTS IN IRA, ERISA, KEOGH OR OTHER PENSION OR PROFIT SHARING PLANS. ITEMIZE. 13. STOCK AND INTERESTS IN INCORPORATED AND UNINCORPORATED BUSINESSES. ITEMIZE.
DESCRIPTION/LOCATION
CURRENT MARKET VALUE.
14. INTERESTS IN PARTNERSHIPS OR JOINT VENTURES. ITEMIZE. 15. GOVERNMENT OR CORPORATE BONDS AND OTHER NEGOTIABLE AND NON-NEGOTIABLE INSTRUMENTS. 16. ACCOUNTS RECEIVABLE 17. ALIMONY, MAINTENANCE, SUPPORT AND PROPERTY SETTLEMENTS TO WHICH YOU ARE OR MAY BE ENTITLED. 18. OTHER LIQUIDATED DEBTS OWED TO YOU, INCLUDING TAX REFUNDS. GIVE PARTICULARS. 19. EQUITABLE OR FUTURE INTEREST, LIFE ESTATES AND RIGHTS OR POWERS EXERCISABLE FOR THE BENEFIT OF THE DEBTOR OTHER THAN THOSE LISTED IN SCHEDULE A REAL PROPERTY. 20. CONTINGENT AND NON-CONTINGENT INTERESTS IN THE ESTATE OF A DECEDENT, DEATH BENEFIT PLAN, LIFE INSURANCE PLAN OR TRUST. 21. OTHER CONTINGENT AND UNLIQUIDATED CLAIMS OF EVERY NATURE, INCLUDING TAX REFUNDS, COUNTERCLAIMS OF THE DEBTOR, AND RIGHTS TO SET OFF CLAIMS. ITEMIZE. GIVE ESTIMATED VALUE OF EACH. 22. PATENTS, COPYRIGHTS, AND OTHER INTELLECTUAL PROPERTY. GIVE DETAILS. 23. LICENSES, FRANCHISES, AND OTHER GENERAL INTANGIBLES. GIVE DETAILS
5
TYPE OF PROPERTY 24. CUSTOMERS LISTS OR OTHER COMPLICATIONS CONTAINING PERSONALLY IDENTIFIABLE INFOR. PROVIDED TO THE DEBTOR BY INDIVIDUALS IN CONNECTION WITH OBTAINING A PRODUCT OR SERVICE FROM THE DEBTOR PRIMARILY FOR PERSONAL, FAMILY, OR HOUSEHOLD PURPOSES. 25. AUTOMOBILES, TRUCKS, TRAILERS OTHER VEHICLES AND ACCESSORIES. 26. BOATS, MOTORS, AND ACCESSORIES 27. AIRCRAFT AND ACCESSORIES. 28. OFFICE EQUIPMENT, FURNISHINGS, AND SUPPLIES 29. MACHINERY, FIXTURES, EQUIPMENT, AND SUPPLIES USED IN BUSINESS. 30. INVENTORY 31. ANIMALS 32. CROPS-GROWING OR HARVESTED.
DESCRIPTION/LOCATION
CURRENT MARKET VALUE
33. FARMING EQUIPMENT AND IMPLEMENTS. 34. FARM SUPPLIES, CHEMICALS, FEED. 35. ALL OTHER PROPERTY OF ANY KIND NOT ALREADY LISTED, SUCH AS SEASONED TICKETS. ITEMIZE.
SECURED DEBTS
List name, mailing address, zip code and account number of all creditors holding claims secured by your property. List all secured debts such as judgment liens, garnishments, statutory liens, auto loans, mortgages, deeds of trust, and other security interests. *Name of Creditor_____________________________________________________ Address ___________________________________________________________ Account number_____________________ date debt incurred_________________ Amount owed __________________describe type of lien______________________
6
Market value of collateral_________ Do you wish to keep collateral and pay debt?___ Debt owed by: Joint________ Husband __________Wife___________ *Name of Creditor_____________________________________________________ Address ___________________________________________________________ Account number__________________________ date debt incurred_____________ Amount owed __________________describe type of lien______________________ Market value of collateral_________Do you wish to keep collateral and pay debt?___ Debt owed by: Joint________ Husband __________Wife___________ *Name of Creditor_____________________________________________________ Address ___________________________________________________________ Account number__________________________ date debt incurred_____________ Amount owed __________________describe type of lien______________________ Market value of collateral_________Do you wish to keep collateral and pay debt?___ Debt owed by: Joint________ Husband __________Wife___________ *Name of Creditor_____________________________________________________ Address ___________________________________________________________ Account number__________________________ date debt incurred_____________ Amount owed __________________describe type of lien______________________ Market value of collateral_________Do you wish to keep collateral and pay debt?___ Debt owed by: Joint________ Husband __________Wife___________
PRIORITY DEBTS
List below all debts of the following type: Alimony, maintenance, child support ; All federal, state, county, or other taxes owed; Wages salaries, commissions you owe to others; money you owe to employee benefit plans; deposits individuals have given you for purchase, lease, or rental of property, student loans; claims of farmers and fisherman.
*Name of Creditor_____________________________________________________ Address ___________________________________________________________
Account number__________________________ date last used (month/year)________ Amount owed __________________ type of debt __________________________ Debt owed by: Joint________ Husband __________Wife______________
7
*Name of Creditor__________________________________________________________ Address __________________________________________________________________ Account number_______________________ date last used (month/year)_______________ Amount owed _____________________ type of debt ____________________________ Debt owed by: Joint________ Husband __________Wife__________ UNSECURED DEBTS List ALL other debts below. Credit cards, medical bills, personal loans, payday loans, car repo. charges, etc. Complete addresses are required. Creditors without addresses cannot be included. *(Please make additional copies if you run out of room)* *Name of Creditor_________________________________________________________ Address _________________________________________________________________ Account number__________________________ date last used (month/year) __________ Amount owed _____________________ What debt was for ________________________ Debt owed by: Joint________ Husband __________Wife_________ *Name of Creditor___________________________________________________________ Address __________________________________________________________________ Account number__________________________ date last used (month/year)_____________ Amount owed __________________What debt was for_______________________ Debt owed by: Joint________ Husband __________Wife___________ *Name of Creditor___________________________________________________________ Address ___________________________________________________________________ Account number__________________________ date last used (month/year)_____________ Amount owed __________________What debt was for_______________________ Debt owed by: Joint________ Husband __________Wife______________ *Name of Creditor____________________________________________________________ Address ___________________________________________________________________ Account number__________________________ date last used (month/year)_____________ Amount owed __________________What debt was for_______________________ Debt owed by: Joint________ Husband __________Wife______________ *Name of Creditor___________________________________________________________
Address ___________________________________________________________________ Account number__________________________ date last used (month/year)____________ 8
Amount owed __________________What debt was for_______________________ Debt owed by: Joint________ Husband _________Wife__________ *Name of Creditor___________________________________________________________ Address ___________________________________________________________________ Account number__________________________ date last used (month/year)_____________ Amount owed __________________What debt was for_______________________ Debt owed by: Joint________ Husband _________Wife__________ *Name of Creditor___________________________________________________________ Address ___________________________________________________________________ Account number__________________________ date last used (month/year)_____________ Amount owed __________________What debt was for_______________________ Debt owed by: Joint________ Husband _________Wife__________ *Name of Creditor____________________________________________________________ Address ____________________________________________________________________ Account number__________________________ date last used (month/year)_____________ Amount owed __________________What debt was for_______________________ Debt owed by: Joint________ Husband _________Wife__________ *Name of Creditor___________________________________________________________ Address ___________________________________________________________________ Account number__________________________ date last used (month/year)_____________ Amount owed __________________What debt was for_______________________ Debt owed by: Joint________ Husband _________Wife__________ *Name of Creditor____________________________________________________________ Address ___________________________________________________________________ Account number__________________________ date last used (month/year)_____________ Amount owed __________________What debt was for_______________________ Debt owed by: Joint________ Husband _________Wife__________ *Name of Creditor___________________________________________________________ Address ___________________________________________________________________ Account number__________________________ date last used (month/year)_____________
Amount owed __________________What debt was for_______________________ Debt owed by: Joint________ Husband _________Wife__________
9
*Name of Creditor___________________________________________________________ Address ___________________________________________________________________ Account number__________________________ date last used (month/year)_____________ Amount owed __________________What debt was for_______________________ Debt owed by: Joint________ Husband _________Wife__________ *Name of Creditor___________________________________________________________ Address ___________________________________________________________________ Account number__________________________ date last used (month/year)_____________ Amount owed __________________What debt was for_______________________ Debt owed by: Joint________ Husband _________Wife__________
INFORMATION ON MEANS TEST
Means Test does NOT apply. Debtor(s) is a disabled veteran with debts incurred primarily during active duty or homeland defense. Whatever that does not pertain to you, please write “None” or “N/A”.
DEPENDENTS
Name 1. 2. 3. 4. Age Relationship to You Is this person/child living with you?
INCOME FROM SIX (6) MONTHS
Please provide the total amount of earned income (from all sources) that you received for the current month and last five (5) months – totaling (6) months of income. DO NOT DEDUCT TAXES. The income you report below is NOT TAKEHOME 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
10
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
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 household expenses: Current Month Last Month 2 Months Ago 3 Months Ago 4 Months Ago 5 Months Ago
11
WIFE: Income received from others who are not filing bankruptcy with you who contribute money to 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
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
LEASES AND CONTRACTS
List all leases and contracts below include timeshare interests, cell phones. Describe the lease or contract and what it is for _____________________________ ___________________________________________________________________ Name and address of other party to contract ________________________________ __________________________________________________________________
CO-DEBTORS
List all parties below who are also liable for debts listed. Include all guarantors and co-signers. Name and address of co-debtor________________________________________ __________________________________________________________________ Name and address of creditor____________________________________________
__________________________________________________________________
12
CURRENT INCOME
Marital status______________ Name, age, of dependents and how they are related to you __________________________________________________________________________ __________________________________________________________________________ Occupation and name of employer________________________________________________ How long employed?_____________ Address of employer____________________________ Spouse Occupation and name of employer__________________________________________ How long employed?_____________ Address of employer____________________________ ____________________________________________________________________________
Current monthly gross income from wages, salaries or commissions YOUR GROSS MONTHLY INCOME
$_________ Estimated monthly overtime $__________
SPOUSE
$___________
$__________
Payroll deductions: (Monthly, Bi-weekly, Weekly)
Federal Withholding tax $_________ Social Security (FICA) tax $___________ Medicare $____________ State withholding tax $_________ Other city/municipal tax $____________ Insurance $____________ Union dues $_________ Other deductions (specify) $_________ OTHER INCOME Income from operation of business, profession, or farm $__________ $ __________
$___________
$___________
$___________
$___________
$___________
$___________
$___________
$__________
13
Income from real property $__________ Income from interest and dividends $__________ Alimony, maintenance support income $__________ Social Security or government assistance (specify) $_________ Pension/retirement income $_________
$__________
$__________
$__________
$__________
$__________
Other monthly income (specify) $_________
$__________
If you expect an increase or decrease of more than 10% in any of the above categories in the next year, please describe ______________________________________________
MONTHLY EXPENSES
List your monthly expenses below. If you and your spouse are filing bankruptcy together but do not live together attach a separate list of spouse's monthly expenses. Rent or mortgage (include lot rented for mobile home) (Are real estate taxes included in mortgage?) if not, list ___________; is property insurance included in mortgage, if not list _________ Electricity and heating fuel Water and sewer Telephone Other utilities (specify) Home maintenance (repairs and upkeep) Food Clothing Laundry and dry cleaning Medical and dental $____________
$____________ $_____________ $_____________ $_____________ $_____________ $_____________ $_____________ $_____________ $_____________ $_____________
14
Transportation (not including car payments) Recreation, clubs, entertainment, newspapers, magazines Charitable contributions MONTHLY EXPENSES (CONTINUED) Insurance (not deducted from wages or included in mortgage payments) __________________ homeowners or renters life health auto other insurance (specify) Taxes (not deducted from wages or included in mortgage (specify type of taxes)__________________ Alimony, maintenance, support you pay Installment Payments, auto Other installment payments Support paid to additional dependents not living with you Expenses from business, profession, farm operation (attach detailed list) Other expenses (specify)
$_____________ $_____________ $_____________
$_____________
$_______________ $_______________ $_______________ $_______________ $_______________
$_______________
$_______________ $_______________
$_______________
$_______________
STATEMENT OF FINANCIAL AFFAIRS
1. Gross income from employment, trade or profession, or business: 2006 2007 2008 you_____________ you_____________ year to date _____________ spouse______________ spouse______________ spouse _____________
(Give source of income, if more than one job)
2. Income other than from employment or operation of business you have received in the last two years: Amount ________________ source____________________
15
3.
Payments to creditors
If less more than half of your debts are primarily consumer debts: List all payments on loans, installment purchases of goods or services, and other debts to any creditor made within 90 days immediately preceding the commencement of this case if the aggregate value of all property that constitutes or is affected by such transfer is not less than $600. Name/Address of Creditor Dates of Payments Amount of Each Payment Total Amount Still Owing
3b. Debtor whose debts are not primarily consumer debts: List all payments or other transfer to any creditor aggregating more than $5,000 in value made within 90 days immediately preceding the commencement of case. Name/address of creditor Dates of payments or Transfers Amount paid or Value of Transfers Amount Still Owing
3c. List all payment made within the last year to creditors who are or were insiders: (including, but not limited to: your relatives, general partners and their relatives, corporations in which you were an officer, director or person in control; affiliates and affiliates insiders; any managing agent) Name/address of creditor date of payment amount paid amount still owed and relationship to you
4. List all suits and administrative proceedings you have been a party to in the last year. Caption of suit and Case number type of proceeding court and location status
4b.List all property that has been attached, garnished or seized under any legal or equitable process within the one year immediately preceding the commencement of this case. Name and address of creditor date of seizure description/value of property
5. List all property that has been repossessed by a creditor, sold at a foreclosure sale, transferred through a deed in lieu of foreclosure or returned to the seller, within one year immediately preceding the commencement of this case. Name and address of creditor or seller date of reposession or Forclosure sale description/value of property
16
6a. Describe any assignment of property for the benefit of creditors made within 120 days immediately preceding the commencement of this case. Name and address of Assignee date of assignment terms of assignment or settlement
6b. List all property which has been in the hands of a custodian, receiver, or court-appointed official within the last year Name and address of custodian name and location of court case title and number date description/value of property
7. List all gifts or charitable contribution made in the last year (except usual and ordinary gifts to family less that $200.00 in value per person and charitable contributions totaling less than $100.00 per recipient) Name and address relationship, if any date description/value
8. List all losses from fire, theft, casualty or gambling in the last year. Description/value of property describe circumstances and insurance payments you received date of loss
9. List all payment made or property transferred to any person, including attorneys, by you or on your behalf, concerning debt consolidation, bankruptcy law or preparation of bankruptcy petitions within the last year. Name and address date amount of money or description/value of property
10. 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 one year immediately preceding the commencement of this case. Name and address of transferree Relationship to Debtor date describe property transferred value received
10b. List all property transferred by the debtor within ten years immediately preceding the commencement of this case to a self-settled trust or similar device of which the debtor is a beneficiary.
17
Name of trust or other device
date
Amount of money or description and value of property or debtor’s interest in the property
11. List all financial accounts and instruments held in your name or for your benefit that were closed, sold or otherwise transferred in the last year. Include checking, savings, financial accounts, certificates of deposit or other instruments, shares and share accounts held in banks, credit unions, pension funds, cooperatives, associations, brokerage houses and other financial institutions. Name and address and account number type of account amount of final balance date
12. List all safe deposit boxes or depositories in which you have held cash, securities or other valuables in the last year. Name and address bank or depository Names and addresses of those with access to box or depository Description of contents date of transfer or surrender
13. List all setoffs made by any creditor, including a bank, against a debt or deposit of yours within the last 90 days. Name and address date amount of set off
14. List all property owned by another person that you hold or control. Name and address description/value of property location of property
15. Individual debtor(s): If the debtor has moved within the three years immediately preceding the commencement of this case, list all premises which the debtor occupied during that period and vacated prior to the commencement of this case. Address name used dates of occupancy
18
16. If you have resided in a community property state, commonwealth or territory (including Alaska, Arizona, California, Idaho, Louisiana, Nevada, New Mexico, Puerto Rico, Texas, Washington or Wisconsin) within the past 6 years, identify the name of your spouse and of any former spouse who resides or resided with you in the community property state.
17. Environmental Information. For the purposes of this question, the following definitions apply: “Environmental Law” means any federal, state, or local statute or regulation regulating pollution, contamination, releases of hazardous or toxic substances, wastes, or material. “Site” means any location, facility, or property as defined under any Environmental Law, whether or not presently or formerly owned or operated by you, including but not limited to, disposal sites. “Hazardous Material” means anything defined as hazardous waster, hazardous substance, toxic substance, hazardous material, pollutant, or contaminant or similar term under Environmental Law.
17a. List the name and address of every site for which the debtor has receive notice in writing by a governmental unit that it may be liable or potentially liable under or in violation of an Environmental Law. Indicate the governmental unit, the date of the notice, and, if known, the Environmental Law. Site Name and Address Name and Address of Governmental Unit Date of Notice Environmental Law
17b. List the name and address of every site for which the debtor 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. Site Name and Address Name and Address of Governmental Unit Date of Notice Environmental Law
17c. List all judicial or administrative proceedings, including settlements or orders, under any Environmental Law with respect to which the debtor is or was a party. Indicate the name and address of the governmental unit that is or was a party to the proceeding, and the docket number. 18. Nat ur e, l ocati on and name of busi ness. ( Sol e pr opr i et or shi p busi nesses onl y) . Name, Taxpayer I.D. and Address Nature of Business Beginning and Ending Dates of operation
19
Prior Bankruptcies If you have filed bankruptcy within the past 6 years give date, case number and location where that case was filed
Pending Bankruptcies If your spouse, partner or affiliate has a bankruptcy pending give person's name, case number, filing date and the relationship to you.
20
Disclaimer
We are non-attorney Bankruptcy Petition Preparers as defined by the U.S. Bankruptcy Code (USC Chapter 1, Sec. 110). We cannot offer or provide legal advice. You understand that we are not attorneys and we can’t provide any legal advice. If you need legal advice, please contact an attorney. Premier Bankruptcy Specialists is not liable for the outcome of your bankruptcy proceeding. All fees are due in advance. If you make the decision not to start on your bankruptcy petition within 48 hours of payment, your fees will be refunded less a $75.00 administration fee. Our services are available to individual consumer-debtors, and sole proprietors who have decided to file on their own behalf, pro se or pro per. Our services are not available to, partnerships or corporations. “We are a debt relief agency. We help people file for bankruptcy relief under the Bankruptcy Code.”
Date: ___________________________
Date: _________________________
_________________________________ Signature of Debtor #1
______________________________ Signature of Debtor #2
Please fax, mail, or email your completed form to:
Premier Bankruptcy Specialists, LLC P.O. Box 25803 Portland, Oregon 97298
Phone: (503) 259-9395 or Toll Free: (866) 532-6859 Fax: (866) 212-5102 Email: PremierBankruptcy@yahoo.com
PRICING INFORMATION Chapter 7 Bankruptcy Preparation: ………………………………………………. $275.00 Emergency Filing (24-hour service) ……………………………………………… $ 75.00 Amendments After Petition is Completed ….…………………………………….. $ 50.00 Face to Face Meetings ……………………………………………………………. $ 40.00 FedEx Overnight Delivery ……………………………………………………….. $ 40.00 USPS Express Delivery ………………………………………………………….. $ 25.00 Credit Reports (Single) ………………………………………………………….. $ 40.00 Credit Reports (Joint) ……………………………………………………………. $ 65.00 Chapter 7 BK & Credit Clean-up (Single) ……………………………………….. $685.00 Chapter 7 BK & Credit Clean-up (Joint) ……………………………………….. $985.00
21