Bankruptcy Questionaire - BANKRUPTCY WORKSHEET INSTRUCTIONS.doc

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					                                      Information Questionnaire
          ATTORNEY FEE
           Chapter 7 - $2,000.00
           Chapter 13 - $4,000.00
           METLAW/HYATT
           ARAG
           LEGAL CARE
           Other: _____________________



      Filing Fee: [ ] $300.00 at signing        [ ] 4 Installments @ $75.00



Case Type:        [ ] Individual           [ ] Husband & Wife              [ ] Partnership
                  [ ] Public Corp.         [ ] Private Corp.               [ ] Municipality
                  [ ] Other: _____________________________

       Chapter: [ ] 7 [ ] 9 [ ] 11 [ ] 12 [ ] 13

         Name: ___________________________________________________________

List all other names used in the last 8 years, e.g., aka, dba, married, maiden, etc.:

           1: ___________________________________________________________

           2: ___________________________________________________________

    SS#/Tax ID#: ______________________________

       Phone #: ______________________________

  Street Address: ___________________________________________________________

City, State, & Zip: ___________________________________________________________


 Mailing Address: ___________________________________________________________

       Line 2: ___________________________________________________________

       Line 3: ___________________________________________________________


SPOUSE INFORMATION (if filing jointly)

         Name: ___________________________________________________________

     aka/dba 1: ___________________________________________________________

           2: ___________________________________________________________


    SS#/Tax ID#: ______________________________

  Street Address: ___________________________________________________________

City, State, & Zip: ___________________________________________________________

Confidential                                        Page 1                                    2/3/2011
Mailing Address: ___________________________________________________________

       Line 2: ___________________________________________________________

       Line 3: ___________________________________________________________

Are you a disabled veteran? [ ]Yes [ ]No


Marital Status: [ ] Married [ ] Single [ ] Divorced [ ] Separated [ ] Separate Expenses


If divorced or separated, are you: [ ] Living Together [ ] Living Apart


DEPENDENTS

                  NAME                                  AGE                               RELATIONSHIP




                   INDIVIDUAL DEBTOR                                   SPOUSE

Occupation:        ________________________                   ____________________________

Employer:          _________________________                  ____________________________

How Long:          _________________________                  ____________________________

Address:           _________________________                  ____________________________

City/State/Zip:    _________________________                  ____________________________


BANKRUPTCIES DURING LAST 8 YEARS:

    Where filed: ___________________________________________________________

    Case Number: _____________________ Date filed: ________________________

    Who filed: [ ] Debtor [ ]Spouse [ ]both




                                                      -2-
PENDING RELATED BANKRUPTCY CASES:

    Debtor Name: ___________________________________________________________

    Case Number: _____________________ Date filed: ________________________

   Relationship: ___________________________________________________________

      District: __________________________ Judge: _________________________


If you lease or rent:

Names of Landlord: _________________________________________________________________
Address of landlord: _________________________________________________________________
TERMS of Lease: __________________________________________________________________
Security Deposit: ____________________________________________________________________




                                        INCOME other than employment

Income from Real Property (RENTALS)                   $ _________      $_________

Interest and Dividends                                $ _________      $_________


Alimony, Maintenance or Support                       $ _________      $_________

Social Security or Government Assistance (Specify):

        _______________________                       $ _________      $_________

        _______________________                       $ _________      $_________


Monthly unemployment compensation
                                                      $ _________      $_________

Pension and Retirement Income                         $ _________      $_________


Other Monthly Income (Specify):

        _________________________                     $ _________      $_________

        _________________________                     $ _________      $_________




                                                      -3-
The operating expenses for how many vehicles are paid out of your household expenses

               [ ]0               [ ]1             [ ] more than 1


List the monthly payments for Vehicle 1                              $ ________
Mileage: ______________________            YEAR/Make/Model: ______________
NAME ON TITLE: ___________________________________________________
NAME ON LOAN: ___________________________________________________


List the monthly payments for Vehicle 2                              $_________
Mileage: ______________________            YEAR/Make/Model: ______________
NAME ON TITLE: ___________________________________________________
NAME ON LOAN: ___________________________________________________



Charitable contributions                           $ _________       $_________

Insurance (not deducted from wages or included in home mortgage payments):

a. Homeowner's or renter's                         $ _________       $_________

b. Life                                            $ _________       $_________

c. Health                                          $ _________       $_________

d. Auto                                            $ _________       $_________

e. Other:__________________________                $ _________       $_________

f. Other:__________________________                $ _________       $_________

g. Other:__________________________                $ _________       $_________


Taxes (not deducted from wages or included in home mortgage)

Specify: ___________________________               $ _________       $_________

Specify: ___________________________               $ _________       $_________


Installment payment

Specify: ___________________________               $ _________       $_________

Specify: ___________________________               $ _________       $_________

Specify: ___________________________               $ _________       $_________

Alimony, maintenance, and support paid to others

                                                   $ _________       $_________

                                                    -4-
Payments for support of additional dependents not living at your home

                                                     $ _________      $_________


Monthly amount that you are required to pay pursuant to court order

                                                     $ _________      $_________

Other expenses not listed above

Specify: __________________________                  $ _________      $_________

Specify: __________________________                  $ _________      $_________

Specify: __________________________                  $ _________      $_________


Education which is a condition of employment and for education that is required for a physically or mentally
challenged dependent child for whom no public education providing similar services is available
                                                                               $ _________

Enter the monthly amount that you expend on childcare                          $ _________

Enter the average monthly amount that you actually expend on health care expenses that are not reimbursed by
insurance or paid by a health savings account
                                                                             $ _________

Health Insurance (if not deducted from payroll)                                $ _________


Disability Insurance      (if not deducted from payroll)                       $ _________

Health Savings Account                                                         $ _________

Reasonable and necessary care and support of an elderly, chronically ill, or disabled member of your household or
member of your immediate family who is unable to pay for such expenses

                                                                               $ _________

The average monthly expenses that you actually incur, not to exceed $125 per child, in providing elementary and
secondary education for your dependent children less than 18 years of age

                                                                               $ _________


CODEBTORS NOT SPOUSE/or Authorized to use account

 Codebtors' Name: ___________________________________________________________

      Address: ___________________________________________________________

      Line 2: ___________________________________________________________

      Line 3: ___________________________________________________________

      ACCOUNTS:____________________________________________________
                                                      -5-
CODEBTORS NOT SPOUSE/or Authorized to use account

 Codebtors' Name: ___________________________________________________________

      Address: ___________________________________________________________

       Line 2: ___________________________________________________________

       Line 3: ___________________________________________________________

      ACCOUNTS:____________________________________________________



Suits and Administrative Proceedings, Executions, Garnishments and Attachments.
   a. List all suits and administrative proceedings to which the debtor is or was a party within one year immediately
preceding the filing of this bankruptcy case. (Married debtors filing under chapter 12 or chapter 13 must include
information concerning either or both spouses whether or not a joint petition is filed, unless the spouses are separated
and a joint petition is not filed.)

       Case title: __________________________________________

       Case number: __________________________________________

  Court and location: __________________________________________

 Nature of proceeding: __________________________________________

Status or disposition
         of case: __________________________________________

 b. Describe all property that has been attached, garnished or seized under any legal or equitable process within one
year immediately preceding the commencement of this case. (Married debtors filing under chapter 12 or chapter 13
must include information concerning property of either or both spouses whether or not a joint petition is filed, unless
the spouses are separated and a joint petition is not filed.)

   Beneficiary of
      seizure: __________________________________________

        Address: __________________________________________

         Line 2: __________________________________________

     Seizure date: __________________________________________

Property description: __________________________________________

         Value: __________________________________________


Repossessions, Foreclosures and Returns.
    List all property that has been repossessed by a creditor, sold at aforeclosure sale, transferred through a deed in lieu
of foreclosure or returned to the seller, during the last 12 months. (Married debtors filing under chapter 12 or chapter
13 must include information concerning property of either or both spouses whether or not a joint petition is filed,
unless the spouses are separated and a joint petition is not filed.)
                                                         -6-
   Creditor/seller: __________________________________________

        Address: __________________________________________

         Line 2: __________________________________________

Property description: __________________________________________

         Value: __________________________________________


Assignments and Receiverships.
    a. Describe any assignment of property for the benefit of creditors during the last 120 days. (Married debtors filing
under chapter 12 or chapter 13 must include any assignment by either or both spouses whether or not a joint petition is
filed, unless the spouses are separated and a joint petition is not filed.)

       Assignee: __________________________________________

        Address: __________________________________________

         Line 2: __________________________________________

          Date: __________________________________________

         Terms: __________________________________________

 b. List all property which has been in the hands of a custodian, receiver, or court-appointed official during the last 12
months. (Married debtors filing under chapter 12 or chapter 13 must include any assignment by either or both spouses
whether or not a joint petition is filed, unless the spouses are separated and a joint petition is not filed.)

       Custodian: __________________________________________

        Address: __________________________________________

         Court: __________________________________________

      Case title: __________________________________________

         Case #: __________________________________________

    Date of order: __________________________________________

Property description: __________________________________________

         Value: __________________________________________


Gifts.
    List all gifts or charitable contributions during the last 12 months except gifts to family members worth under $200
per individual, and except charitable contributions worth under $100 per recipient. (Married debtors filing under
chapter 12 or chapter 13 must include gifts or contributions by either or both spouses whether or not a joint petition is
filed, unless the spouses are separated and a joint petition is not filed.)

       Recipient: __________________________________________

        Address: __________________________________________

                                                        -7-
         Line 2: __________________________________________

   Relationship to
         debtor: ________________________________________

     Date of gift: __________________________________________

     Description: __________________________________________

          Value: __________________________________________
Losses.
   List all losses from fire, theft, other casualty or gambling duringthe last 12 months. (Married debtors filing under
chapter 12 or chapter 13 must include losses by either or both spouses whether or not a joint petition is filed, unless the
spouses are separated and a joint petition is not filed.)

       Property: __________________________________________

         Value: __________________________________________

    Circumstances: __________________________________________

 Insurance coverage: __________________________________________

     Date of loss: __________________________________________

Other Transfers.
        a. List all other property transferred, either absolutely or as a security, during the last 24 months, except as
usual in your business or in your financial affairs. (Married debtors filing under chapter 12 or chapter 13 must include
transfers by either or both spouses whether or not a joint petition is filed, unless the spouses are separated and a joint
petition is not filed.)

       Transferee: __________________________________________

Relationship to debtor: __________________________________________

   Date of transfer: __________________________________________

        Property: __________________________________________

          Value: __________________________________________

          b. 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 was a beneficiary.

       Transferee: __________________________________________

Relationship to debtor: __________________________________________

   Date of transfer: __________________________________________

        Property: __________________________________________

          Value: __________________________________________

Closed Financial Accounts.
   List all financial accounts in your name or held for your benefit, which were closed, sold, or otherwise transferred
during the last 12 months. Include checking, savings, and other accounts, certificates of deposit and other instruments;
shares and share accounts held in banks, credit unions, pension funds, cooperatives, associations, brokerage houses and
                                                        -8-
other financial institutions. (Married debtors filing under chapter 12 or chapter 13 must include information
concerning accounts or instruments held by or for either or both spouses whether or not a joint petition is filed, unless
the spouses are separated and a joint petition is not filed.)


     Institution: __________________________________________

        Address: __________________________________________

         Line 2: __________________________________________

   Type of account: __________________________________________

       Account #: __________________________________________

    Final balance: _______________ Closing Date: __________

Safe Deposit Boxes.
    List each safe deposit or other box or depository in which the debtor has or had securities, cash, or other valuables
during the last 12 months. (Married debtors filing under chapter 12 or chapter 13 must include boxes or depositories of
either or both spouses whether or not a joint petition is filed, unless the spouses are separated and a joint petition is not
filed.)


     Institution: __________________________________________

        Address: __________________________________________

         Line 2: __________________________________________

 Person with access: __________________________________________

        Address: __________________________________________

         Line 2: __________________________________________

       Contents: __________________________________________

   Surrender date: __________________________________________

Setoffs.
   List all setoffs made by any creditor, including a bank, against a debt or deposit of the debtor, during the last 90
days. (Married debtors filing under chapter 12 or chapter 13 must include information concerning either or both
spouses whether or not a joint petition is filed, unless the spouses are separated and a joint petition is not filed.)


       Creditor: __________________________________________

        Address: __________________________________________

         Line 2: __________________________________________

     Setoff date: __________________________________________

         Amount: __________________________________________




                                                         -9-
Property Held for Another Person.
  List all property owned by another person that the debtor holds or controls.

         Owner: __________________________________________

        Address: __________________________________________

         Line 2: __________________________________________

       Property: __________________________________________

     Description: __________________________________________

         Value: __________________________________________

       Location: __________________________________________


Nature, Location and Name of Business.

   a. If the debtor is an individual, list the names, addresses, taxpayer identification numbers, nature of the businesses,
and beginning and ending dates of all businesses in which the debtor was an officer, director, partner, or managing
executive of a corporation, partnership, sole proprietorship, or was a self-employed professional within the six years
immediately preceding the commencement of this case, or in which the debtor owned 5 percent or more of the voting
or equity securities within the six years immediately preceding the commencement of this case.

     If the debtor is a partnership, list the names, addresses, taxpayer identification numbers, nature of the businesses,
and beginning and ending dates of all businesses in which the debtor was a partner or owned 5 percent or more of the
voting or equity securities, within the six years immediately preceding the commencement of this case.

    If the debtor is a corporation, list the names, addresses, taxpayer identification numbers, nature of the businesses,
and beginning and ending dates of all businesses in which the debtor was a partner or owned 5 percent or more of the
voting or equity securities within the six years immediately preceding the commencement of this case.


      Business Name: __________________________________________

 Taxpayer I.D. Number: __________________________________________

          Address: __________________________________________

           Line 2: __________________________________________

   Nature of business: __________________________________________

 Beginning and Ending Dates:

                  Start Date:          ______________              End Date: ______________




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