Client Questionnaire For Non-Business Debtor. Section 1 Basic Information
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1 Client Questionnaire For Non-Business Debtor Section 1 Basic Information Part A. Name and Address Name: Last First Middle Telephone Number Home: Work: Cell: Other: Fax: Social Security Number: - - Driver' License No.: Expiration Date: Date of Birth: Address: City: State: Zip: County: Have you lived at this address for at least 180 days? No Yes Have you lived at this address for at least 730 days (2 years)? No Yes Part B. Name and Address of Spouse Please fill in the following information about your spouse: Name: Last First Middle Telephone Number Home: Work: Cell: Other: Fax: Social Security Number: - - Driver' License No.: Expiration Date: Date of Birth: Are you planning to file this case jointly with your spouse? No Yes Part C. Prior/Pending Bankruptcy Cases Have you or your spouse filed any other bankruptcy case in the last 8 years? No Yes Debtors Who Reside as Tenants of Residential Property If you rent your home, does a landlord hold a judgment against you? No Yes Page 1 of 5
2 Section 2 Property You Own Part A. Real Estate (Schedule A) List all real estate which you own or are a joint owner of, even if you still owe money on the property. Address and description of each piece of property: Example: 3BR/2.5BA single family home on 2 acres of land. Purchased in 2005 for $150,000". How much is this property currently worth? List all mortgages, home equity loans, and liens: What s the name of your mortgage company? Please specify if this is a 1 st or 2 nd mortgage. How much do you still owe on the mortgage(s)? What is your monthly payment? Are you behind on the payments? (If so, # of payments behind) Part B. Personal Property (Schedule B) For each type of property listed below, indicate whether you own any property of that category, and, if you do, fill in the remaining information. You can think of the value as the replacement value. For property acquired for personal or family use, replacement value is the price a retail merchant would charge for a property of that kind, considering the age and condition of that property. Yes Type of Property or No Description & Location Checking/Savings Account & other bank accounts How much is it worth? Household goods, furniture, including audio, video, and computer equipment Motor vehicles: Please go to and look up the RETAIL value of your vehicle(s), and write the amount(s) in the far right column. Year, make & model, and miles on odometer: Page 2 f 5
3 Section 3 Debts List below all debts that you owe, or that creditors claim that you owe. Type of Debt Creditor Name and Address Amount owed Home loans, mortgages, or liens Car loans Student loans Credit/charge cards Unpaid medical bills Unpaid taxes Unpaid alimony or child support All other unpaid debts/bills Page 3 of 5
4 Section 4 Current Income Marital Status: Married Single Divorced Separated Widowed Domestic Partner Part A. Debtor s Income List all dependents of you and your spouse, their ages, and their relationship to you: Name Age Relationship Part B. Joint Debtor s Income 1. What is your occupation? 2. Name and address of your employer: 3. How long have you been employed there? 4. What is the gross amount of your paycheck, before taxes/other deductions are taken out? $ 5. How often do you get paid? once a week every two weeks twice a month once a month other 6. Do you receive overtime/bonus pay outside of your salary? If so, how much per pay period? $ 7. How much is taken out of each paycheck for taxes and social security? $ 8. How much is taken out for all insurance? $ 9. Are there other deductions? If so, what are they and how much? Do you receive a) income from business operations outside of your regular paycheck listed above? If so, what is the business and how much do you receive per month? b) income from real estate property? If so, how much per month? c) interest or dividends? If so, how much per month? d) alimony or family support payments for your use or for the care of your dependents? If so, how much per month? e) social security or other forms of monetary government assistance? No Yes $ f) retirement or pension money? No Yes$ Do you have any other sources of income not listed? No Yes 1. What is your spouse s occupation? 2. Name and address of your spouse s employer: 3. How long employed there? 4. What is the gross amount of your spouse s paycheck, before taxes/other deductions? $ 5. How often does he/she get paid? once a week every two weeks twice a month once a month other 6. Does your spouse receive overtime/bonus pay outside of your salary? How much per pay period? $ 7. How much is taken out of each paycheck for taxes and social security? $ 8. How much is taken out for all insurance? $ 9. Are there other deductions? If so, what are they and how much? Does your spouse receive a) income from business operations outside of the regular paycheck listed above? If so, what is the business and how much does your spouse receive per month? b) income from real estate property? If so, how much per month? No Yes $ c) interest or dividends? If so, how much per month? d) alimony or family support payments for spouse s use or for care of dependents? If so, how much per month? No Yes $ e) social security or other forms of monetary government assistance? No Yes $ f) retirement or pension money? No Yes$ Does your spouse have any other income not listed? No Yes Are you or your spouse expecting any increase or decrease in salary next year? If so, explain. Page 4 of 5
5 Section 6 Current Expenses The following questions ask for your expenses each month. If you are unsure of the amount you pay each month, but know the amount for a different period (per week, per day, every 2 months, etc.,), write in the amount and the frequency that you pay the amount. Indicate how much you pay for each item each month 1. your rent or your mortgage payment (first mortgage only) $ Does that amount include real estate taxes? No Yes Does it include property insurance? No Yes 2. electricity and heating $ 3. water and sewage $ 4. telephone service/long distance $ 5. Do you have any other utility bills? If so, what, and how much per month? $ 6. home maintenance, including repairs and general upkeep $ 7. food $ 8. clothing $ 9. laundry and dry cleaning $ 10. medical and dental expenses $ 11. transportation (not including car payments) $ 12. entertainment, recreation, newspapers, magazines $ 13. charitable contributions $ 14. insurance not deducted from paycheck a) homeowner s or renter s insurance $ b) life insurance $ c) health insurance $ d) auto insurance $ 15. taxes not deducted from paycheck $ 16. installment payments (for 2 nd mortgage, car, furniture, etc.) (Specify) $ $ $ 17. alimony, maintenance, support paid to others $ 18. childcare $ 19. education expense for your children under 18 $ 20. other expenses not listed above: _Car tag(s) $ Personal grooming (haircuts) $ $ $ When you are done, please send the Questionnaire to us: Kenneth A. Parker, P.C. P.O. Box 550, Buford, Georgia Phone: (678) / Fax: (678) / sparker@kenparker.com Page 5 f 5 Client Questionnaire 2013
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