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BANKRUPTCY INFORMATION WORKSHEETS

INSTRUCTIONS: The questions in these worksheets should be answered by the person who is considering a bankruptcy filing. In most cases, this means an individual, or an individual and their spouse. When a corporation is considering a filing, the term "you" in these worksheets refers to the corporation itself.

Answer each question completely and truthfully. If more space is needed to completely answer a question, complete the answer on a separate sheet of paper or on the back of the worksheet. If you do not understand a question, write "Don't Understand" after the question so you can discuss it with an attorney at a later time. Do not guess at the answer to any question. If a question doesn't apply to you, write "Not Applicable" after the question.

The value listed for any item should be the estimated present fair market value of the item without regard to any lien, mortgage, or encumbrance. To value any item, consider what you could get for it if you sold "as is" through a broker, classified ads, or a garage sale. Remember that many times the present fair market value of an item is much less than the amount it's purchase price.

WARNING: You should be as accurate as possible in filling out these worksheets. They may later be used to prepare official bankruptcy forms which will be submitted to the Court. Failure to disclose assets in a bankruptcy case is a federal crime punishable by imprisonment for up to five years and by a fine of up to $5,000. In addition, if the bankruptcy forms do not contain complete and accurate information, your case may be dismissed or converted by the Bankruptcy Court.

I. PRELIMINARY INFORMATION

Fill in the following chart which provides general information about yourself and your spouse (if applicable):

YOUR NAME (First, Middle, Last):
 SPOUSES NAME (First, Middle, Last):
ALL OTHER NAMES used in the past 6 years:



 ALL OTHER NAMES used by spouse in the past 6 years:
SOCIAL SECURITY / TAX I.D. NOS.
(If more than one, list all.):



 SPOUSE'S SOCIAL SECURITY / TAX I.D. NOS.
(If more than one, list all.):
STREET ADDRESS:
 SPOUSE'S STREET ADDRESS (if different from yours):
MAILING ADDRESS (if different from street address):



 SPOUSE'S MAILING ADDRESS
(if different from street address):
IN WHAT COUNTY HAVE YOU LIVED, OR CONDUCTED BUSINESS, FOR THE GREATER PART OF THE LAST 180 DAYS?



 IN WHAT COUNTY HAS YOUR SPOUSE LIVED, OR CONDUCTED BUSINESS, FOR THE GREATER PART OF THE LAST 180 DAYS?
IF YOU ARE A SOLE PROPRIETOR OF A BUSINESS, briefly describe the nature of the business:



 IF YOUR SPOUSE IS A SOLE PROPRIETOR OF A BUSINESS, briefly describe the nature of the business:
PRIOR BANKRUPTCIES: If you have previously filed a bankruptcy petition, list the case number, date and location of that filing:



 PRIOR BANKRUPTCIES: If your Spouse has previously filed a bankruptcy petition, list the case number, date and location of that filing:
PENDING BANKRUPTCIES: If any immediate family member or business partner has a bankruptcy pending, list the case name and number, where and when it was filed, and their relation to you:



 PENDING BANKRUPTCIES: If any immediate family member or business partner of your Spouse has a bankruptcy pending, list the case name and number, where and when it was filed, and their relation to your Spouse:

II. YOUR ASSETS

A. REAL PROPERTY

If you own or have any interest in any real estate, complete the following showing each parcel of real estate in which you own or have an interest. If you do not own any assets of this type, write "NONE" in the first box of the chart.

DESCRIPTION AND LOCATION OF PROPERTY NATURE OF YOUR INTEREST IN THE PROPERTY (Joint tenancy, tenancy in common, life estate, etc.) DATE ACQUIRED AND PURCHASE PRICE CURRENT MARKET VALUE AMOUNT OF EACH MORTGAGE OR LIEN AGAINST THE PROPERTY



























































B. PERSONAL PROPERTY

NOTE: If you do not own any assets of the type mentioned in each question, write "NONE" in the box which follows.

1. How much cash will you have on hand when this case is filed? $________________

2. If you have any accounts, deposits, or shares in any bank, credit union or financial institution, provide the following information:

TYPE OF ACCOUNT
(Checking, savings, CD, etc.) 		NAME OF BANK OR FINANCIAL INSTITUTION AMOUNT OF DEPOSIT
OR BALANCE IN ACCOUNT


















3. If you have any security deposits with a landlord, telephone company, utility company, or
anyone else, provide the following information:

WHO HAS DEPOSIT (Landlord, power company, etc.) AMOUNT OF DEPOSIT








4. If you own any household goods or furnishings, including audio, video, or computer
equipment, provide the following information:

GENERAL DESCRIPTION AND LOCATION OF ITEMS MARKET VALUE IF SOLD








5. If you own any books, pictures, art objects, antiques, stamps, coins, records, tapes, compact discs, or other collections or collectibles, provide the following information:

GENERAL DESCRIPTION AND LOCATION OF ITEMS MARKET VALUE IF SOLD








6. If you own any clothes or wearing apparel, provide the following information:

GENERAL DESCRIPTION AND LOCATION OF ITEMS MARKET VALUE IF SOLD








7. If you own any furs or jewelry, provide the following information:

GENERAL DESCRIPTION AND LOCATION OF ITEMS MARKET VALUE IF SOLD








8. If you own any firearms, sports equipment, photographic equipment, or other hobby equipment, provide the following information:

GENERAL DESCRIPTION AND LOCATION OF ITEMS MARKET VALUE IF SOLD








9. If you own any interests in any type of life insurance, provide the following information:

NAME OF INSURANCE COMPANY AND DESCRIPTION OF POLICY SURRENDER VALUE OF POLICY








10. If you have an interest in an annuity, provide the following information:

NAME OF ISSUER AND DESCRIPTION OF ANNUITY VALUE OF ANNUITY








11. If you own an interest in an IRA, Keogh, ERISA qualified, or other type of pension or profit sharing, provide the following information:

DESCRIPTION OF PLAN PRESENT VALUE OF PLAN








12. If you own any stock in a corporation or other business, provide the following information:

DESCRIPTION OF STOCK OR BUSINESS INTEREST PRESENT VALUE OF STOCK OR BUSINESS INTEREST








13. If you own an interest in any partnership, joint venture or other business, provide the following information:

DESCRIPTION OF BUSINESS INTEREST PRESENT VALUE OF BUSINESS INTEREST








14. If you own any government or corporate bonds or any negotiable or non-negotiable instruments, provide the following information:

DESCRIPTION OF BOND OR INSTRUMENT PRESENT VALUE








15. If you own any accounts receivable or if anyone owes you money, provide the following information:

DESCRIPTION OF RECEIVABLES OR NAME OF PERSON WHO OWES YOU MONEY VALUE OR AMOUNT DUE








16. If you are owed any accrued and unpaid spousal or child support, or property settlement payments, provide the following information:

NAME OF PERSON WHO OWES YOU MONEY AND DESCRIPTION OF MONEYS DUE AMOUNT DUE








17. If you are you owed any tax refunds or payments, provide the following information:

DESCRIPTION OF REFUND DUE AMOUNT DUE








18. If you have an interest in any trusts or security interests or future interests in any property, provide the following information:

DESCRIPTION OF EACH INTEREST PRESENT VALUE








19. If you own or have an interest of any kind in the estate of a deceased person, in a death benefit plan, in the death benefits in a life insurance policy, or in a trust, provide the following information:

DESCRIPTION OF EACH INTEREST PRESENT VALUE








20. If you have any contingent and unliquidated claims of any kind, including counterclaims or rights to a setoff, provide the following information:

DESCRIPTION OF EACH SUCH CLAIM PRESENT VALUE







21. If you own or have interest in any patents, copyrights, or other intellectual property, provide the following information:

DESCRIPTION OF EACH PATENT OR COPYRIGHT PRESENT VALUE








22. If you own or have interest in any licenses, franchises or other general intangibles, provide the following information:

DESCRIPTION OF EACH ITEM PRESENT VALUE








23. If you own or have an interest in any automobiles, trucks, trailers, vehicles or accessories, provide the following information:

DESCRIPTION OF EACH ITEM PRESENT VALUE








24. If you own or have an interest in any boats, motors or accessories, provide the following information:

DESCRIPTION OF EACH ITEM PRESENT VALUE








25. If you own or have an interest in any aircraft or accessories, provide the following information:

DESCRIPTION OF EACH ITEM PRESENT VALUE








26. If you own or have an interest in any office equipment, furnishings and supplies, provide the following information:

DESCRIPTION OF EACH ITEM PRESENT VALUE








27. If you own or have an interest in any machinery, fixtures, equipment or supplies used in business, provide the following information:

DESCRIPTION OF EACH ITEM PRESENT VALUE












28. If you own or have an interest in any inventory, provide the following information:

DESCRIPTION AND LOCATION OF INVENTORY PRESENT VALUE








29. If you own or have an interest in any animals, provide the following information:

DESCRIPTION AND LOCATION OF EACH ANIMAL PRESENT VALUE








30. If you own or have an interest in any crops, growing or harvested, provide the following information:

DESCRIPTION OF EACH ITEM PRESENT VALUE








31. If you own or have an interest in any farming equipment or implements, provide the following information:

DESCRIPTION OF EACH ITEM PRESENT VALUE








32. If you own or have an interest in any farm supplies, chemicals or feed, provide the following information:

DESCRIPTION OF EACH ITEM PRESENT VALUE








33. If you own or have an interest in any other property or assets not already listed, provide the following information:

DESCRIPTION OF EACH ITEM PRESENT VALUE








II. YOUR DEBTS

A. SECURED DEBTS

Secured debts are home loans, home equity loans, second montages, car loans, or other liens where an asset has been pledged as security for repayment of a debt. All other loans are usually considered unsecured. If you have any secured loans, provide the following:

NAME AND ADDRESS OF CREDITOR ACCOUNT NO. AND DATE LOAN WAS INCURRED DESCRIPTION OF PROPERTY SUBJECT TO LIEN TOTAL AMOUNT DUE ON LOAN
















































B. PRIORITY DEBTS

Priority debts usually get paid before others and many are times are nondischargable in a bankruptcy. For most, this means taxes and support payments. If you have any such debts, complete the following:

FOR TAXES:

Name and address of creditor Date claims was incurred Amount due


















FOR SUPPORT:
Name and address of creditor Date claims was incurred Amount due












C. UNSECURED DEBTS

Please provide the following: (You can make copies of this page if you have more creditors.)

CREDITORS NAME, ADDRESS AND ACCT. NUMBER TYPE OF DEBT
(Credit card, personal loan, lawsuit, etc.) and
DATE DEBT WAS INCURRED 		AMOUNT DUE


































































































C. EXECUTORY CONTRACTS AND UNEXPIRED LEASES

If you have any such debts, complete the following:

NAME, ADDRESS AND ACCOUNT NUMBER OF CONTRACT OR LEASE DESCRIPTION OF CONTRACT OR LEASE




















D. CODEBTORS

If anyone else besides you and your spouse are liable for any of your debts, complete the following:

NAME, AND ADDRESS OF CODEBTOR NAME, AND ADDRESS OF CREDITOR




















III. YOUR INCOME

YOUR DEPENDENTS:

NAME AGE RELATIONSHIP TO YOU


















YOUR EMPLOYMENT:


YOU YOUR SPOUSE
OCCUPATION



NAME OF EMPLOYER



HOW LONG EMPLOYED



ADDRESS OF EMPLOYER



MONTHLY INCOME: (Estimate of average monthly income.)


YOU YOUR SPOUSE
GROSS MONTHLY WAGES and COMMISSIONS, INCLUDING OVERTIME



LESS:



Payroll taxes



Insurance



Union Dues



Other



NET MONTHLY INCOME



OTHER INCOME:



NET REGULAR INCOME FROM OPERATION OF BUSINESS



INCOME FROM REAL PROPERTY



INTEREST AND DIVIDENDS



CHILD AND SPOUSAL SUPPORT



SOCIAL SECURITY AND OTHER GOVT. ASSISTANCE



PENSION OR RETIREMENT



OTHER MONTHLY INCOME









TOTAL MONTHLY INCOME

III. YOUR EXPENSES

(If spouses are separated, but filing together, each should fill out a separate expense schedule.)


AMT.
RENT OR MORTGAGE PAYMENT
Are real estate taxes included? Yes No
Is property insurance included? Yes No
UTILITIES: Electric and heating fuel
Water and Sewer
Telephone
Other
HOME MAINTENANCE
FOOD
CLOTHING
LAUNDRY AND DRY CLEANING
MEDICAL AND DENTAL EXPENSE (not including insurance pmts.)
TRANSPORTATION (not including car pmts.)
RECREATION, NEWSPAPERS, AND MAGAZINES
CHARITABLE CONTRIBUTIONS
INSURANCE: Homeowner's or renter's
Life
Health
Auto
Other
TAXES (not deducted from your wages)
INSTALLMENT PAYMENTS: Auto
Other
CHILD OR SPOUSAL SUPPORT
OTHER SUPPORT PAYMENTS




TOTAL MONTHLY EXPENSES

IV. STATEMENT OF FINANCIAL AFFAIRS

NOTE: If your answer to any question is "none," write "NONE" in the box which follows the question.

1. List your gross income for each of the past three years.


YOU YOUR SPOUSE
INCOME SO FAR THIS YEAR



LAST YEAR



YEAR BEFROE LAST



2. If you have received any income other than from sources other than from your employment or business in any of the past three years, provide the following information:


YOU YOUR SPOUSE
INCOME SO FAR THIS YEAR



LAST YEAR



YEAR BEFROE LAST



3a. If you have paid any creditor more than $600 in the last 90 days, provide the following information:

NAME AND ADDRESS OF CREDITOR DATES OF PAYMENT AGGREGATE AMOUNT PAID IN LAST 90 DAYS AMOUNT STILL OWING
















3b. If you have paid any creditor who was an "insider" (family members, business associates, partners, or corporations which you or your family or business associates own or control) in the last 365 days, provide the following information:

NAME AND ADDRESS OF CREDITOR, AS WELL AS RELATIONSHIP TO YOU DATES OF PAYMENT TOTAL AMT. PAID IN LAST 90 DAYS AMOUNT STILL OWING
















4a. If you been a party to a lawsuit in the past 365 days, provide the following information:

NAME OF CASE AND CASE NUMBER NATURE OF CASE COURT LOCATION CASE STATUS




















4b. If any of your property has been attached, seized or garnished in the past 365 days, provide the following information:

NAME AND ADDRESS OF CREDITOR DATE OF SEIZURE DESCRIPTION OF PROPERTY SEIZED VALUE OF PROPERTY
















5. If you have had any repossessions, foreclosures or returns in the past 365 days, provide the following information:

NAME AND ADDRESS OF CREDITOR DATE OF REPOSSESSION, FORECLOSURE OR RETURN DESCRIPTION OF PROPERTY VALUE OF PROPERTY
















6a. If you have assigned any assets to creditors in the past 365 days, provide the following information:

NAME AND ADDRESS OF CREDITOR DATE OF ASSIGNMENT DESCRIPTION OF ASSETS VALUE OF ASSETS
















6b. If any of your property has been held by a custodian, receiver, or other court appointed official during the last 365 days, provide the following information:

NAME AND ADDRESS OF CUSTODIAN DATE OF ORDER LOCATION OF COURT AND CASE NO. DESCRIPTION AND VALUE OF ASSETS
















7. If you have made any gifts in the past 365 days, provide the following information:

NAME, ADDRESS AND RELATION OF RECIPIENT TO YOU DATE OF GIFT DESCRIPTION OF GIFT VALUE OF GIFT
















8. If you have had any losses from fire, theft, other casualty, or gambling in the past 365 days, provide the following information:

TYPE OF LOSS AND DESCRIPTION OF ASSET LOST DATE OF LOSS AMOUNT OF LOSS COVERED BY INSURANCE?


















9. If you have consulted with, and paid, an attorney or other person regarding filing bankruptcy in the past 365 days, provide the following information:

NAME AND ADDRESS OF PERSON PAID DATE OF PAYMENT AMOUNT PAID












10. If you have transferred any money or property (including the granting of a security interest), other than transfers in the course of ordinary business affairs, to any person in the last 365 days, provide the following information:

NAME AND ADDRESS OF TRANSFEREE, AS WELL AS RELATIONSHIP TO YOU DATES OF TRANSFER DESCRIPTION OF ASSET TRANSFERRED VALUE OF ASSET TRANSFERRED
















11. If you have closed or transferred any bank accounts in the last 365 days, provide the following information:

NAME AND ADDRESS OF FINANCIAL INSTITUTION NAME AND TYPE OF ACCOUNT CLOSING BALANCE DATE OF CLOSING
















12. If you have had any safe deposit boxes in the last 365 days, provide the following information:

NAME AND ADDRESS OF BANK OR DEPOSITORY NAME ON ACCOUNT DESCRIPTION OF CONTENTS DATE OF CLOSING
















13. If any creditor, including a bank, made a setoff against a debt or deposit of yours in the last 90 days, provide the following information:

NAME AND ADDRESS OF FINANCIAL INSTITUTION NAME AND TYPE OF ACCOUNT AMOUNT OF SETOFF DATE OF SETOFF
















14. If you hold or control any asset which really belongs to another person, provide the following information:

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
















15. If you have not lived at the same address for the past 24 months, provide the following information:

PREVIOUS ADDRESS DATES OF OCCUPANCY








NOTE: Questions 16 - 21 ONLY need to be answered if these forms are being filled out for a corporation, partnership, or an individual who, within the past 2 years, has: (1) been an officer, director, or owner of 5% or more of a corporation, been a partner in a partnership, or (3) been a sole proprietor or otherwise self-employed.

16. If you have been involved in any business in the past two years, provide the following information:

NAME AND ADDRESS OF BUSINESS NATURE OF BUSINESS BEGINNING AND ENDING DATES OF OPERATION
























17a. List all bookeepers and accountants who supervised or kept records of the business in the past 6 years:

NAME AND ADDRESS OF BOOKEEPER OR ACCOUNTANT DATES SERVICES RENDERED








17b. List all firms or individuals who have audited the books or records, or prepared a financial statement for the business in the past 2 years:

NAME AND ADDRESS DATES SERVICES RENDERED








17c. List all firms or individuals who were in possession of the books or records for the business in the past 2 years:

NAME AND ADDRESS




17d. List all firms, creditors, or financial institutions to whom a financial statement has been issued in the past 2 years:

NAME AND ADDRESS DATES ISSUED








18a. If you have taken any inventories of the business, provide the following information for the past 2 inventories:

DATE OF INVENTORY SUPERVISOR DOLLAR AMT. ( Specify cost, market, or other)












18b. List the name and address of each person who has the records of the inventories listed above:

NAME AND ADDRESS DATES OF INVENTORY








19a. If these forms are being filled out for a partnership, provide the following information for each partner:

NAME AND ADDRESS NATURE OF INTEREST PERCENTAGE OF INTEREST


















19b. If these forms are being filled out for a corporation, provide the following information for each officer, director, and person who owns or controls 5% or more of the stock in the corporation:

NAME AND ADDRESS TITLE (Officer, director, or shareholder PERCENTAGE OF INTEREST


















20a. If these forms are being filled out for a partnership, provide the following information for each partner who withdrew from the partnership in the past year:

NAME, ADDRESS AND DATE OF WITHDRAWAL NATURE OF INTEREST PERCENTAGE OF INTEREST


















20b. If these forms are being filled out for a corporation, provide the following information for each officer, director, and person who owned or controlled 5% or more of the stock in the corporation but withdrew in the past year:

NAME , ADDRESS AND DATE OF WITHDRAWAL TITLE (Officer, director, or shareholder PERCENTAGE OF INTEREST


















21. If these forms are being filled out for a partnership or corporation, provide the following information for every withdrawal or distribution credited or given to an insider in any form, in the past year:

NAME , ADDRESS AND RELATIONSHIP TO DEBTOR DATE AND PURPOSE AMT. OF MONEY OR DESCRIPTION AND VALUE OF PROPERTY DISTRIBUTED






















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