- PDF Free Download

Size: px

Start display at page:

Download ""

Merilyn Millicent Webb
5 years ago
Views:

1 / BANKRUPTCY INFORMATION FORM As non-lawyer bankruptcy petition preparers, we are not legally permitted to give you any advice or assistance in filling out these forms. We are only permitted to type the information you put on these forms. You may need to do some research on the internet or seek legal advice from an attorney on how to fill these forms out properly. TYPE OF BANKRUPTCY YOU WANT TOFILE: CHAPTER (7 OR 13) TYPE OF FILING (INDIVIDUAL OR JOINT BANKRUPTCY) ARE YOU (MARRIED, SINGLE, DIVORCED, WIDOW, SEPARATED) IF MARRIED, DOES YOUR SPOUSE LIVE WITH YOU (Y OR N) HAVE YOU BEEN A RESIDENT OF FLORIDA FOR AT LEAST 180 DAYS (Y OR N) HAVE YOU FILED ANY OTHER BANKRUPTCIES IN THE PAST 8 YEARS (Y OR N) FORMERCASE# DATE LOCATION YOUR COMPLETE NAME SS # ALL OTHER NAMES USED IN LAST 6 YEARS DA TE OF BIRTH DRIVERS LICENSE # HOME PHONE # WORK # AGE: RESIDENTIAL ADDRESS MAILING ADDRESS COUNTY EMPLOYER OCCUPATION ADDRESS ~ HOW LONG EMPLOYED THERE: DEPENDENTS AGE RELA TIONSHIP DEPENDENTS AGE RELA TIONSHIP DEPENDENTS AGE RELATIONSHIP SPOUSE'S COMPLETE NAME SS # ALL OTHER NAMES USED IN LAST 6 YEARS RESIDENTIAL ADDRESS MAILING ADDRESS COUNTY EMPLOYER OCCUPATION ADD RESS HOW LONG EMPLOYED THERE:

2 YOUR PROPERTY 1. IF YOU OWN A HOIVIE: description of home is it homesteaded? YIN How much is it worth $ how much do you owe on it $ Date you purchased this What is your intention for this property (check one): Reaffirm Redeem Surrender 2. If you own any other homes or land: description ofproperty-:---:-- How much is it worth $ how much do you owe on it $ Addressofthisproperty: Date you purchased this What is your intention for this property (check one): Reaffirm Redeem Surrender 3. If you own a car: Year, make & model Replacement value $ Payoff on car loan $ Date you purchased this What is your intention for this property (check one): Reaffirm Redeem Surrender If you own another car: Year, make & model Replacement value $ Payoff on car loan $ ---. Date you purchased this :----:-----c-::---- What is your intention for this property (check one): Reaffirm Redeem Surrender 4. List your household possessions (furniture & appliances etc.) in your home and how much its worth and when you purchased them: List any furniture or appliances that you are still paying for and who is financing it and the date of purchased What is your intention for this property (check one): Reaffirm Redeem Surrender 5. How much are your clothes worth $ List all your Jewelry and howmuch it is worth 7. If you have anything else that has any value such as tax refunds, deposits, boats, collectibles, expensive tools, guns, etc. list them here and what they are worth: 8. List all of your bank accounts: Bank name Account # Type Balance you keep there $ Bank name Account # Type Balance you keep there $ 9. If you lease/rent a car or apartment list the address where you make your payments: 10. If you have a pension or profit sharing plan list where its kept and how much you have in it: 11. If you own any stock or IRA's, list the type and how much they are worth

3 Debtor(s) Case No. SCHEDULE C - PROPERTY CLAIMED AS EXEMPT Debtor elects the exemptions to which debtor is entitled under: o Check if debtor claims a homestead exemption that exceeds $125,000. (Check one box) o 1 ~ U.S.C. 522(b)(2) i4j~u.s.c. 522(b)(3) DESCRIPTION OF PROPERTY SPECIFY LAW PROVIDING EACH EXEMPTION CURRENT MARKET VALUE OF CLAIMED VALUE OF PROPERTY EXEMI'l'ION WITHOUT DEDUCTING EXEMPTIONS c-, 8 I(fJ E " LL o E tu: N w co o o '"oa '" SCHEDULE C - PROPERTY CLAIMED AS EXEMPT

4 HOW OFTEN PAID REGULAR WAGES OVERTIME CHILD SUPPORT SELF-EMPLOYED RENTAL INCOME PENSION GOVT ASSISTANCE Type of assistance MONTHLY DEBTOR INCOME INFORMATION SPOUSE ***************************************************************************** DEDUCTIONS FROM YOUR PAY: TAXES INSURANCE UNION DUES CHILD SUPPORT PENSION OTHER TOTAL MONTHL Y EXPENSES MORTGAGE/RENT ELECTRIC WATER PHONE OTHER UTILITIES CABLE HOME MAINTENANCE FOOD CLOTHING LAUNDRY MEDICAL GAS FOR VEHICLE RECREATION CHARITY DONATIONS CHURCH OFFERINGS DOES IT INCLUDE PROPERTY TAX OUT OF POCKET INSURANCE: HOME LIFE HEALTH AUTO OTHERINSUR IRS BACK TAXES CAR PAYMENTS 2ND CAR ALIMONY CHILD SUPPORT BUSINESS EXP DAY CARE OTHER EXPENSES INSURANCE

5 , \ I List all of your pay for the past 6 months Date paid Regular pay Overtime Total gross pay Taxes Misc Deduction Amount I ( I I t I

Form B22A (Chapter 7) (10/05) According to the calculations required by this statement: In re Case---------------------- The presumption No: does not arise STATEMENT OF CURRENT MONTHLY INCOME AND

6 Form B22A (Chapter 7) (10/05) According to the calculations required by this statement: In re Case The presumption No: does not arise STATEMENT OF CURRENT MONTHLY INCOME AND MEANS TEST CALCULATION FOR USE IN CHAPTER 7 ONLY In addition to Schedule I and J, this statement must be completed by every individual Chapter 7 debtor, whether or not filing jointly, whose debts are primarily consumer debts. Joint debtors may complete one statement only. ::m):::):)::)t):):):::;:::mi:::::::::::m).!:::::::::::::::=i:::::::::::::)::: l!att::*:~:::e* u.u$*an::~(),n.:::q*$l4bcj;j):::"j;1fe~n.$::::p:}:::::?::::~:::l::;::::::::::::j:::::::f:i):::::::::::t:::::: If you are a disabled veteran described in the Veteran's Declaration in this Part I, (1) type the letter "X" in the box below next to the Veteran's Declaration, and (2) complete the verification in Part VIII. Do not complete any of the remaining parts of this statement. Veteran's Declaration. By typing the letter "X" In this box, I declare under penalty of perjury that I am a disabled veteran (as defined in 38 U.S.C. 3741(1») whose indebtedness occurred primarily during a period in which I was on active duty (as defined in 10 U.S.C. 101(d)(1)) or while I was performing a homeland defense activity (as defined in 32 U.S.C. 901(1)). Marital/filing status. Placean "XU in the box that appliesand completethe balance of this part of this statement as directed. a. Unmarried.Complete only Column A ("Debtor's Income) for Lines b. Married, not filing jointly, with declaration of separate households. By checking this box, debtor declares under penalty of perjury: "My spouse and I are legally separated under applicable nonbankruptcy law or my spouse and I are living apart other than for the purpose of evading the requirements of 707(b)(2)(A) of the Bankruptcy Code." Complete only Column A ("Debtor's Income") for Lines c. d. Married, not filing jointly, without the declaration of separate households set out in Line 2.b above. Complete both Column A ("Debtor's Income'~) and Column B (Spouse's Income) for Lines Married, filing jointly. Complete both Column A ("Debtor'S Income") and Column B (Spouse's Income) for Lines All figures must reflect average monthly income for the six calendar months prior to filing the bankruptcy case, ending on the last.day of the month before the filing, If you received different, amounts of income during these six months, you must total the amounts received during the six months, divide this total by six, and enter the result on the appropriate line. Column A Debtor's Income Column B Spouse's Income Gross wages, salary, tips, bonuses, overtime, commissions. Income from the operation of a business, profession or farm. Enter gross receipts from business in Line a and ordinary and necessary expenses in Line b. Do not include any part of the business expenses entered on Line b as a deduction in Part V. a., b. c. Gross receipts Ordinary and necessary business expenses Business income Rent and other real property income. Enter gross receipts from real property In Line a and ordinary and necessary expenses in Line b. Do not include any part of the operating expenses entered on Line b as a deduction in Part V. a. Gross receipts b. Ordinary and necessary business expenses c. Business income' $ $ Form B22A (Ch. 7) (10/05) Page 1 of 5 M.D.FI~.

7 FINANCIAL AFFAIRS 1. How much income have you made this year Last year The Year before that 2. If you received any other type of income (pension, child support, etc.) list how much you received in each category over the past 24months a. List any company that you have paid more than $600 over the past 3 months. Amounts Paid $ Dates paid Remaining balance $ I Amounts Paid $ Dates paid Remaining balance $ I Amounts Paid $ Dates paid Remaining balance $ 3b. List all payments or transfers of over $5,000 made to any friend or family member over the past 3 months Amounts Paid $ Dates paid Balance $ Relationship to you: 4a. If you were involved in any Lawsuits over the past 12 months: CAPTION OF SUIT NATURE OF SUIT COURT & LOCATION CASE # STATUS 4b. Have you had any of your wages, checking accounts or tax refunds garnished in the past 12 months? NAME OF GARNISHER DATE SEIZED DESCRIPTION AND VALUE 5. List any Repossessions, Foreclosures, or Voluntary returns you had in the past 12 months: Description: Date Value $ Description: Date Value $ 7. Have you made any donations or gifts to a charity, church or family member of over $200 in the past 12 months? NAME & ADDRESS RELATIONSHIP DATE DESCRIPTION / VALUE 8. List any losses that you had from either theft, an accident or gambling in the past 12 months: Description Date Amount of Loss $

8 9. List any payments you have made in the last 12 months for either bankruptcy or debt counseling Description: Date Amount $ List all property that you have either sold, given away, transferred or titled over in the past 12 months: Description: Date Value $ Description: Date Value $ 11. List any checking or savings accounts that you have closed in the past 12 months. NAME AND ADDRESS TYPE & ACCOUNT # FINAL BALANCE DATE 12. If you had a safe deposit account in the past 12 months: Name & Address ofbank Contents: Date Closed Value $ If you are using property that doesn't belong to you Name & Address of owner: Description: Value $ Name & Address of owner: Description: Value $ 15. List all prior addresses other than your current address where you have lived in the past 3 years ADDRESS NAME USED DATES MOVED IN & OUT, -, 16. List any former spouses you were married to in the past 8 years: 17. If you owned or were an officer of a small business/partnership/corporation in the past 6 years: Name & address of business Tax ID # Beginning & Ending dates of business: Name & Address of Accountant : -----~ Name & address of any Banks that have your financial statements: "- How much have you paid yourself over the past 12 months $ List all other officers of the company

9 United States Bankruptcy Court Middle District of Florida INRE: Case No. "....~.n.!?e~.~.!!.~.n.)..~?~l ~ Chapter.:. Debtor(s) NOTICE TO DEBTOR BY NON-ATTORNEY BANKRUPTCY PETITION PREPARER. I am a bankruptcy petition preparer. I am not an attorney and may not practice law or give legal advice. Before preparing any document for filing as defined in 110(a)(2) of the Bankruptcy Code or accepting any fees, I am required by law to provide you with this notice concerning bankruptcy petition preparers. Under the law, 110 of the Bankruptcy Code (11 U.S.C. 110), I am forbidden to offer you any legal advice, including advice about any of the following: whether to file a petition under the Bankruptcy Code (11 U.S.c. 101 et seq.); whether commencing a case under chapter 7, 11, 12, or 13 is appropriate; whether your debts will be eliminated or discharged in a case under the Bankruptcy Code; whether you will be able to retain your home, car, or other property after commencing a case under the Bankruptcy Code; concerning the tax consequences of a case brought under the Bankruptcy Code; concerning the dischargeability of tax claims; whether you mayor should promise to repay debts to a creditor or enter into a reaffirmation agreement with a creditor to reaffirm a >- debt; 8! concerning how to characterize the nature of your interests in property or your debts; or cil concerning bankruptcy procedures and rights. E ~ In addition, under 11 U.S.C. 110(h), the Supreme Court or the Judicial Conference of the United States may promulgate rules or " guidelines setting a maximum allowable fee chargeable by a bankruptcy petition preparer. As required by law, I have notified you ofthe ~ maximum amount, if any, before preparing any document for filing or accepting any fee from you. 00 m 6o "? o c g -. u: fij co Signature of Debtor o o '"~ m Date Joint Debtor (if any) -,',', Date DECLARATION AND SIGNATURE OF NON-ATTORNEY BANKRUPTCY PETITION PREPARER (See 11 U.S.C. 110) ill I declare under penalty of perjury that: (l) I am a bankruptcy petition pre parer as defined in 11 U.S.C. 110; (2) I prepared this document for compensation and have provided the debtor with a copy of this document and the notices and information required under 11 U.S.c. 110(b), 110(h), and 342 (b); and, (3) if rules or guidelines have been promulgated pursuant to 11 U.S.c. 110(h) setting a maximum fee for services chargeable by bankruptcy petition preparers, I have given the debtor notice of the maximum amount before preparing any document for filing for a debtor or accepting any fee from the debtor, as required by that section. ~~Jf!~y..b:.l:llU ~ ,, Printed or Typed Name and Title, if any, of Bankruptcy Petition Pre parer Social Security No. (Required by II USC. l l Il.) If the bankruptcy petition preparer is not all individual, stale the name, title (if any), address, and social security number of the officer, principal, responsible person, or partner who signs the document.?~.?'.?j.q}!g..!r~~l ~.~.C!~.2.nyiJ!~,.f.I,,..~.?~.1Q.. Address... '.. Signature of Bankruptcy Petition Preparer Date,'.. ::.~. :-.=.::;:-; :.. :.;. ~::... :... -: Names and Social Security numbers of all other individuals who prepared or assisted in preparing this document, unless the bankruptcy petition preparer is not an individual: If more than one person prepared this document, attach additional signed sheets conforming to the appropriate Official Form for each person. A bankruptcy petition preparer's failure to comply with the provision of title 11 and the Federal Rules of Bankruptcy Procedure may result infines or imprisonment or both. 11 iis.c. 110; 18 u.s.e NOTICE TO DEBTOR BY NON-ATTORNEY BANKRUPTCY PETITION PRE PARER

Black and Buono P.C. DEBTOR S QUESTIONNAIRE

Black and Buono P.C. DEBTOR S QUESTIONNAIRE 1. Have you ever filed, or had filed against you, any type of Petition under any of the bankruptcy laws of the United States? No Yes 1A. Please complete Schedule