Thomas K. Atwood BANKRUPTCY WORKSHEET
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- Irma Dickerson
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1 Thomas K. Atwood Attorney at Law Aurora Avenue North, Suite #202, Shoreline, WA Voice (425) or (206) Fax (815) tom@tomlaw.com Web Page: BANKRUPTCY WORKSHEET PLEASE ANSWER ALL QUESTIONS TO THE BEST OF YOUR ABILITY. IF YOU DO NOT HAVE THE INFORMATION REQUESTED, LEAVE BLANK AND BRING IT TO MY ATTENTION DURING OUR FREE CONSULTATION. PLEASE FEEL FREE TO CALL ME AT THE NUMBER ABOVE WITH ANY QUESTIONS CONCERNING THIS FORM OR THE BANKRUPTCY PROCESS. NAME & OTHER INFORMATION:(DEBTOR) NAME: CITY/STATE/ZIP: PHONE NUMBER: ALT NUMBER: AGE: SOCIAL SECURITY NUMBER: OTHER NAMES USED IN LAST 6 YEARS:(Include maiden, aka, etc.): PRIOR ADDRESSES/PAST THREE YEARS: 1. CITY/STATE/ZIP: DATES OF RESIDENCY: FROM: to 2. CITY/STATE/ZIP: DATES OF RESIDENCY: FROM: to WHERE DID YOU HEAR ABOUT THOMAS K. ATWOOD, ATTORNEY AT LAW? (Please Circle One) Sign at Office Google, Yahoo or other Web Based Search AT&T/Yellowpages.com Craigslist YELP NOLO.COM Referral PRINT or ONLINE? Thomas K. Atwood - Attorney at Law PAGE 1
2 JOINT-DEBTOR (spouse if filing jointly): NAME: CITY/STATE/ZIP: PHONE NUMBER: ALT NUMBER: AGE: SOCIAL SECURITY NUMBER: OTHER NAMES USED IN LAST 6 YEARS:(Include maiden, aka, etc.): PRIOR BANKRUPTCY Have you or your spouse filed for Bankruptcy before? (circle one) Yes No When?: Where?: Chapter 7 or Chapter 13?: (circle one if applicable) 7 13 Please provide your case # if available: What was the disposition of your case?: FILING INFORMATION Will you be filing by yourself or with your spouse? Please check the statement that applies: Filing as: Individual Individual married and living apart Individual married and living together Joint and living together Joint and living apart Are you or your spouse in business? Not in business Currently in business Prior business with the past 2 years Type of business:(briefly describe operation): Sole proprietor, Partnership or Corporation?: Thomas K. Atwood - Attorney at Law PAGE 2
3 CREDIT COUNSELING SESSION A Credit Counseling Session is mandatory PRIOR to filing your Bankruptcy. A list of the independent organizations who have programs approved by the United States Trustee s Office can be found at: or please ask me to or print out the current list for you. You must complete the credit counseling session within the 180 days PRIOR to filing Bankruptcy. Programs are available in person, via the internet, or by telephone, and take about an hour to complete. I am recommending for the credit counseling which charges a $10 fee per credit counseling class if you take it online. They automatically send my office your certificate of completion when the class is completed if you enter in my address tom@tomlaw.com which is very convenient, and you can pay for the course online with your debit card. PERSONAL FINANCIAL MANAGEMENT COURSE There is also a mandatory Personal Financial Management program that can be taken AFTER you file but must completed PRIOR to discharge. The current list of approved providers can be found at: You should pay about $10 for this class at or I can also recommend and Thomas K. Atwood - Attorney at Law PAGE 3
4 I WILL NEED THE FOLLOWING DOCUMENTS PRIOR TO FILING YOUR CASE. Please bring these documents with you to the consult if available. You can bring copies if you wish, or I can have your originals scanned when you come in. If you do not have all of these documents for the consultation, don t be concerned. There will be plenty of time to obtain the required supporting documents. 1. Last 6 months of pay statements received for you and your spouse, even if your spouse is not filing for bankruptcy with you. If you do not have the last 6 months of statements, bring in the most recent ones you have. Also bring in any statements regarding retirement, disability, unemployment compensation or other income. 2. If you have a BUSINESS or are SELF-EMPLOYED, please bring in a recent yearto-date profit and loss statement, along with your last 2 months of bank statements. Also please generate a profit and loss statement for the past 6 months, as we will need that information to qualify you through the means test. 3. Tax returns for the last two years if completed and filed. If you have unfiled returns, please bring that to my attention at the consult. 4. If you are making payments on your automobile(s), please bring in the last statement from your auto lender, and also the year and date it was financed. It is important to ascertain when the vehicle was purchased and/or financed to fully advise you of your options. 5. If you have internet access, please obtain your credit reports online per the instructions on the last page of this questionnaire and bring them to the consult. The three major reporting bureaus are Experian, Equifax and TransUnion, and all reports can be obtained for free online once per year from If you do obtain them online, please a copy to my office at tom@tomlaw.com, or print them out to bring in. If you do not wish to get your reports on your own, I can obtain all 3 of them in a merged report from a commercial source for a $40 fee if you are filing by yourself, or a $60 fee for reports for both you and your spouse. 6. If you own real estate, please bring in your most recent mortgage statements. If you have a recorded homestead on the property, please bring a copy of that also. It will also be important to determine the current value of your real estate. If you have had any recent appraisals or comparables done on the property (within 6 months), please bring those with you, or perhaps speak with a knowledgeable local real estate agent, and get a written comparative market analysis (CMA) if possible. (Available for free from most real estate brokers/salespersons) 7. Also a good idea to bring in the latest statement from each creditor, including collections agencies and law offices for accounts that are in collections. Thomas K. Atwood - Attorney at Law PAGE 4
5 PROPERTY QUESTIONS REAL PROPERTY: (Circle One) HOUSE CONDO VACANT LOT OTHER: LOCATION OF PROPERTY IF DIFFERENT FROM RESIDENCE: NATURE OF INTEREST: WHOLE 1/2 1/3 OTHER: DO YOU HAVE A CO-OWNER?: WHAT YEAR DID YOU PURCHASE THIS PROPERTY? WHAT DID YOU PAY FOR THE PROPERTY? MARKET VALUE OF PROPERTY: ARE PROPERTY TAXES OWED? FROM WHAT YEARS?: FIRST TRUST DEED HOLDER: CITY/STATE/ZIP: BALANCE OWED: YEAR LOAN TAKEN OUT: ACCOUNT # (LAST 4 DIGITS IS FINE): MONTHLY PAYMENT: HOA DUES? - HOW MUCH PER MONTH? DOES THE MONTHLY PAYMENT INCLUDE IMPOUNDS FOR INSURANCE/TAXES? ARE PAYMENTS CURRENT?: IF BEHIND IN PAYMENTS, HOW MANY/HOW MUCH?: Thomas K. Atwood - Attorney at Law PAGE 5
6 SECOND TRUST DEED HOLDER: CITY/STATE/ZIP: AMOUNT OWED: YEAR LOAN TAKEN OUT: ACCOUNT # (LAST FOUR DIGITS): MONTHLY PAYMENT: HOA DUES? - HOW MUCH PER MONTH? ARE PAYMENTS CURRENT?: IF BEHIND IN PAYMENTS, HOW MANY/HOW MUCH?: Please list any additional encumbrances or liens against the property. If you are not sure, it may be a good idea to obtain a preliminary title report to show exactly what is in your chain of title. ATTACH ADDITIONAL SHEETS FOR OTHER REAL PROPERTY ANSWERING ALL THE QUESTIONS ABOVE FOR EACH PROPERTY Thomas K. Atwood - Attorney at Law PAGE 6
7 PERSONAL PROPERTY YOU MUST LIST ALL OF YOUR PROPERTY, EVEN IF YOU DO NOT HAVE POSSESSION OF IT. THIS INCLUDES EVERYTHING - WHEREVER IT MAY BE LOCATED INCLUDING PROPERTY IN OTHER STATES OR COUNTRIES. THIS ALSO INCLUDES ANY COMMUNITY PROPERTY IN POSSESSION OF YOUR CURRENT OR EX-SPOUSE. PLEASE PROVIDE CURRENT AS IS VALUE - WHAT THE PROPERTY IN ITS CURRENT CONDITION AND AGE WOULD BRING IN A PRIVATE SALE SUCH AS A CRAIGLIST SALE. PLEASE ITEMIZE ALL ITEMS WITH A VALUE IN EXCESS OF $500 PER ITEM - ALL OTHER SMALLER ITEMS CAN BE GROUPED ( Misc. household furnishings; Misc. tools; Misc. jewelry, etc. ) IT IS EXTREMELY IMPORTANT TO LIST ALL PROPERTY SO WE CAN DETERMINE WHAT CAN BE CLAIMED EXEMPT AND RETAINED - THE BANKRUPTCY CODE REQUIRES THAT ALL PROPERTY BE LISTED, AND YOU WILL BE SIGNING A DECLARATION UNDER PENALTY OF PERJURY THAT THE LIST OF PROPERTY YOU FILE WITH THE COURT IS CORRECT AND COMPLETE. CASH: $ (Total for currency, coins) LIST ALL BANK ACCOUNTS INCLUDING CHECKING/SAVINGS/CD'S/MONEY MARKET FUNDS BANK: TYPE OF ACCOUNT: ACCOUNT #: BALANCE: BANK: TYPE OF ACCOUNT: ACCOUNT #: BALANCE: USE ADDITIONAL SHEETS IF NECESSARY Thomas K. Atwood - Attorney at Law PAGE 7
8 SECURITY DEPOSITS WITH LANDLORDS OR UTILITIES: NAME OF PERSON OR COMPANY HOLDING DEPOSIT: AMOUNT OF DEPOSIT: NAME OF PERSON OR COMPANY HOLDING DEPOSIT: AMOUNT OF DEPOSIT: BOOKS/PICTURES/COLLECTIONS (Paintings, Prints, Stamp Collections/Baseball Cards): JEWELRY & FURS (Wedding bands, necklaces, rings, etc.): FIREARMS, SPORTING & HOBBY EQUIPMENT: Thomas K. Atwood - Attorney at Law PAGE 8
9 FURNITURE: STEREOS/TVs/CAMERAS/CAMCORDERS/OTHER ELECTRONICS: ALL OTHER HOUSEHOLD FURNISHINGS/PROPERTY: Thomas K. Atwood - Attorney at Law PAGE 9
10 LIFE INSURANCE POLICIES/WHOLE LIFE POLICIES: (Please indicated whether insurance is "term" or "whole life" and provide cash surrender value if applicable.) COMPANY: COMPANY: COMPANY: COMPANY: CASH VALUE: CASH VALUE: CASH VALUE: CASH VALUE: STOCKS, BONDS, ANNUITIES, ETC.: (Attached additional sheet if necessary - please provide current statement from all brokerage accounts held showing stocks and portfolio value: COMPANY: SHARES: PRESENT VALUE: COMPANY: SHARES: PRESENT VALUE: COMPANY: SHARES: PRESENT VALUE: IRAs, KEOGHs, 401Ks, PENSION OR PROFIT SHARING PLAN: Please provide recent statements from each pension, IRA or profit sharing Plan PLAN: WHERE: CAN YOU WITHDRAW THESE FUNDS?: IF SO, WHEN AND HOW?: WHAT IS THE CASH VALUE?: PLAN: WHERE: CAN YOU WITHDRAW THESE FUNDS?: IF SO, WHEN AND HOW?: WHAT IS THE CASH VALUE?: Thomas K. Atwood - Attorney at Law PAGE 10
11 MONEY OWED TO YOU INCLUDING: JUDGMENTS, SUPPORT ARREARS, PROPERTY SETTLEMENTS, TAX REFUNDS, EXPECTED INHERITANCES: LIST ALL POSSIBLE SOURCES. SOURCE: EXPECTED AMOUNT: WHEN DO YOU EXPECT THESE FUNDS?: SOURCE: EXPECTED AMOUNT: WHEN DO YOU EXPECT THESE FUNDS?: SOURCE: EXPECTED AMOUNT: WHEN DO YOU EXPECT THESE FUNDS?: AUTOMOBILES, TRUCKS, BOATS, TRAILERS AND OTHER MOTOR VEHICLES: PLEASE PROVIDE COPY OF PURCHASE CONTRACT IF FINANCED VEHICLE #1 MAKE: YEAR: MODEL: OPTIONS: MILEAGE: CONDITION: GOOD FAIR POOR CURRENT FAIR MARKET VALUE: IS VEHICLE SECURITY FOR A LOAN?: YES NO NAME OF CREDITOR: CITY/STATE/ZIP: DATE OF PURCHASE: (IMPORTANT IF FINANCED!!) AMOUNT PAID: ARE PAYMENTS CURRENT?: CURRENT BALANCE ON LOAN: MONTHLY PAYMENT: DO YOU PLAN TO KEEP THIS VEHICLE?: DO YOU HAVE A CO-SIGNER ON THIS LOAN?: NAME OF CO-SIGNER/ Thomas K. Atwood - Attorney at Law PAGE 11
12 VEHICLE #2 MAKE: YEAR: MODEL: OPTIONS: MILEAGE: CONDITION: GOOD FAIR POOR CURRENT FAIR MARKET VALUE: IS VEHICLE SECURITY FOR A LOAN?: YES NO NAME OF CREDITOR: CITY/STATE/ZIP: DATE OF PURCHASE: (IMPORTANT IF FINANCED!!) AMOUNT PAID: ARE PAYMENTS CURRENT?: CURRENT BALANCE ON LOAN: MONTHLY PAYMENT: DO YOU PLAN TO KEEP THIS VEHICLE?: DO YOU HAVE A CO-SIGNER ON THIS LOAN?: NAME OF CO-SIGNER/ VEHICLE #3 MAKE: YEAR: MODEL: MILEAGE: CONDITION: GOOD FAIR POOR CURRENT FAIR MARKET VALUE: IS VEHICLE SECURITY FOR A LOAN?: YES NO NAME OF CREDITOR: CITY/STATE/ZIP: DATE OF PURCHASE: (IMPORTANT IF FINANCED!!) AMOUNT PAID: ARE PAYMENTS CURRENT?: CURRENT BALANCE ON LOAN: MONTHLY PAYMENT: DO YOU PLAN TO KEEP THIS VEHICLE?: DO YOU HAVE A CO-SIGNER ON THIS LOAN?: Thomas K. Atwood - Attorney at Law PAGE 12
13 PLEASE ATTACH ADDITIONAL SHEETS FOR OTHER VEHICLES/BOATS/ETC. ANY OTHER PROPERTY NOT MENTIONED ABOVE - PLEASE MAKE CERTAIN YOU HAVE LISTED ALL OF YOUR PROPERTY: WHAT: WHERE: FMV: WHAT: WHERE: FMV: WHAT: WHERE: FMV: WHAT: WHERE: FMV: WHAT: WHERE: FMV: WHAT: WHERE: FMV: WHAT: WHERE: FMV: Thomas K. Atwood - Attorney at Law PAGE 13
14 BUSINESS DEBTORS ONLY 14. ACCOUNTS RECEIVABLE: HOW MUCH?: HOW OLD ARE THESE RECEIVABLES?: DO YOU EXPECT THESE RECEIVABLES TO BE PAID?: IF YOU HAVE SUBSTANTIAL RECEIVABLES, PLEASE ATTACH AN ACCOUNTING SHOWING AMOUNTS, FROM WHOM AND WHEN INCURRED. 15. BUSINESS EQUIPMENT AND OFFICE SUPPLIES: WHAT: HOW MANY: FAIR MARKET VALUE (FMV): WHAT: HOW MANY: FAIR MARKET VALUE (FMV): WHAT: HOW MANY: FAIR MARKET VALUE (FMV): WHAT: HOW MANY: FAIR MARKET VALUE (FMV): WHAT: HOW MANY: FAIR MARKET VALUE (FMV): Thomas K. Atwood - Attorney at Law PAGE 14
15 BUSINESS DEBTORS ONLY 16. INVENTORY: WHAT: HOW MANY: FAIR MARKET VALUE: HOW DID YOU COME BY THIS VALUATION?: WHAT: HOW MANY: FAIR MARKET VALUE: HOW DID YOU COME BY THIS VALUATION?: WHAT: HOW MANY: FAIR MARKET VALUE: HOW DID YOU COME BY THIS VALUATION?: WHAT: HOW MANY: FAIR MARKET VALUE: HOW DID YOU COME BY THIS VALUATION?: Thomas K. Atwood - Attorney at Law PAGE 15
16 TAX LIABILITIES DO YOU HAVE ANY OUTSTANDING TAX LIABILITIES? YES NO a. Personal income tax? YES NO Federal or State? FEDERAL STATE From what years & for how much? b. 941 taxes? (Payroll/Employee taxes)? YES NO From what years & for how much? c. Property taxes? YES NO From what years, for how much and on which property? DOES THE FEDERAL OR STATE GOVERNMENT HOLD A LIEN AGAINST YOUR PROPERTY? (Federal tax lien, etc. - Please describe - attach lien notices) ANY OTHER TAX LIABILITIES? PLEASE ATTACH ANY NOTICES AND/OR STATEMENTS YOU HAVE RECEIVED FROM THE FEDERAL OR STATE TAXING AUTHORITIES REGARDING TAX LIABILITY Thomas K. Atwood - Attorney at Law PAGE 16
17 DEBTOR QUESTIONS - CURRENT AND PAST INCOME GROSS INCOME FROM EMPLOYMENT, TRADE, PROFESSION, BUSINESS INCOME: (Please list your annual gross income for the years requested - please locate and provide your tax returns for these years if possible) (SELF EMPLOYED please provided a current year to date profit and loss statement showing gross income and deductible expenses) PLEASE PROVIDE A COMPLETE COPY OF YOUR LAST FILED TAX RETURN HUSBAND INCOME 2018 (SO FAR): SOURCE: WIFE INCOME 2018 (SO FAR): SOURCE: INCOME 2017: INCOME 2017: SOURCE: SOURCE: INCOME 2016: INCOME 2016: SOURCE: SOURCE: ANY OTHER SOURCES OF INCOME (Rentals, Unemployment comp., disability, pension, etc.): HUSBAND INCOME 2018 (SO FAR): SOURCE: AMOUNT: WIFE INCOME 2018 (SO FAR): SOURCE: AMOUNT: INCOME 2017: INCOME 2017: SOURCE: AMOUNT: SOURCE: AMOUNT: INCOME 2016: INCOME 2016: SOURCE: AMOUNT: SOURCE: AMOUNT: Thomas K. Atwood - Attorney at Law PAGE 17
18 HAVE YOU MADE ANY PAYMENTS TO ANY CREDITOR OVER THE LAST 3 MONTHS ADDING UP TO MORE THAN $600 TO THAT CREDITOR? a. WHO? ITEMIZE PAYMENTS: b. WHO? ITEMIZE PAYMENTS: c. WHO? ITEMIZE PAYMENTS: HAVE YOU MADE ANY LARGE PAYMENTS TO A FAMILY MEMBER, FRIEND OR BUSINESS ASSOCIATE OVER THE LAST YEAR (OVER $1000 IN TOTAL TO THAT ONE FAMILY MEMBER, FRIEND OR ASSOCIATE)? a. WHO? ITEMIZE PAYMENTS: b. WHO? ITEMIZE PAYMENTS: c. WHO? ITEMIZE PAYMENTS: Thomas K. Atwood - Attorney at Law PAGE 18
19 LAWSUITS AND ADMINISTRATIVE PROCEEDINGS, EXECUTIONS, GARNISHMENTS AND ATTACHMENTS WITHIN ONE YEAR OF FILING THIS BANKRUPTCY?(Please describe): REPOSSESSIONS, FORECLOSURES AND RETURNS WITHIN ONE YEAR OF FILING THIS BANKRUPTCY?(Please describe): LOSSES FROM FIRE, THEFT OR GAMBLING?(Please describe): PAYMENTS MADE TO OTHERS FOR DEBT COUNSELING OR BANKRUPTCY?: Thomas K. Atwood - Attorney at Law PAGE 19
20 ANY TRANSFERS OF PROPERTY (HOUSES/LARGE SUMS OF MONEY OR OTHER BIG TICKET ITEMS) WITHIN ONE YEAR PROCEEDING THIS BANKRUPTCY?: CLOSED, SOLD OR TRANSFERRED ACCOUNTS WITHIN THE LAST YEAR?: SAFE DEPOSIT BOXES MAINTAINED WITHIN THE PAST YEAR?: PROPERTY YOU ARE HOLDING FOR ANOTHER PERSON?: EXECUTORY CONTRACTS, UNEXPIRED LEASES OR TIMESHARES?: Thomas K. Atwood - Attorney at Law PAGE 20
21 BUDGET OF DEBTOR AND SPOUSE INCOME DEBTOR EMPLOYER'S NAME: EMPLOYER'S ADDRESS CITY/STATE/ZIP: OCCUPATION AND/OR NATURE OF BUSINESS: WHEN DID YOU START THERE?: JOINT DEBTOR/SPOUSE EMPLOYER'S NAME: EMPLOYER'S ADDRESS CITY/STATE/ZIP: OCCUPATION AND/OR NATURE OF BUSINESS: WHEN DID YOU START THERE?: CURRENT INCOME/MONTHLY: PLEASE ATTACH YOUR 3 MOST RECENT PAY STATEMENTS AND LAST YEAR'S TAX RETURN - IF YOU ARE SELF-EMPLOYED, ATTACH A DETAILED PROFIT AND LOSS STATEMENT YEAR TO DATE AND YOUR LAST 2 TAX RETURNS CURRENT MONTHLY GROSS WAGES, SALARY & COMMISSIONS: ESTIMATED MONTHLY OVERTIME: SUBTOTAL CURRENT INCOME: PAYROLL DEDUCTIONS: FIT, SIT & FICA (TAXES): INSURANCE: UNION DUES: SUBTOTAL DEDUCTIONS: NET WAGES, SALARY & COMMISSION: INCOME CONTINUED: HUSBAND WIFE Thomas K. Atwood - Attorney at Law PAGE 21
22 NET INCOME FROM OPERATION OF BUSINESS: (ATTACH PROFIT & LOSS STATEMENT) INCOME FROM REAL PROPERTY: INTEREST AND DIVIDENDS: SPOUSAL OR CHILD SUPPORT RECEIVED: SOCIAL SECURITY OR GOVERNMENT BENEFITS: PENSION OR RETIREMENT INCOME: OTHER MONTHLY INCOME: TOTAL MONTHLY INCOME: DESCRIBE ANY INCREASE OR DECREASE OF MORE THAN 10% ANTICIPATED IN ANY OF THE ABOVE INCOME CATEGORIES OVER THE NEXT YEAR: DEPENDENTS OF DEBTOR AND SPOUSE(minors 18 & under): NAME: AGE: SEX: NAME: AGE: SEX: NAME: AGE: SEX: NAME: AGE: SEX: NAME: AGE: SEX: NAME: AGE: SEX: Thomas K. Atwood - Attorney at Law PAGE 22
23 CURRENT MONTHLY EXPENDITURES OF DEBTOR AND JOINT DEBTOR: (Fill out separate column for spouse only if separated, otherwise, combine expenditures in one column) HUSBAND WIFE 1. RENT OR 1 st MORTGAGE PAYMENT: INCLUDES IMPOUNDS FOR TAXES?: YES NO If not, how much are property taxes per month? INCLUDES IMPOUNDS FOR INSURANCE?: YES NO If not, how much is fire/homeowner/renter s insurance? Home maintenance, repair and upkeep expense: HOA Dues/Condominium Fees per month: If you have a 2 nd mortgage or HELOC, how much per month? 2. UTILITIES: ELECTRICITY; HEATING FUEL; GAS: WATER, SEWER and GARBAGE: TELEPHONE, CELL PHONES, INTERNET CABLE AND SATELLITE: OTHER UTILITIES: 3. FOOD and HOUSEKEEPING SUPPLIES: 4. CHILDCARE and CHILDREN S EDUCATION COSTS: 5. CLOTHING, LAUNDRY and DRY CLEANING: 6. PERSONAL CARE PRODUCTS AND SERVICES: 7. MEDICAL and DENTAL EXPENSES: 8. TRANSPORTATION (GAS, OIL, REPAIRS): Includes public transportation if any 9. ENTERTAINMENT, RECREATION: Includes newspapers, magazines, books, movies 10. CHARITABLE CONTRIBUTIONS: Includes church tithing, offering, cash/check donations only 11. INSURANCE (not deducted directly on pay statements): LIFE: HEALTH: AUTO: 12. INSTALLMENT PAYMENTS: VEHICLE #1 VEHICLE #2 VEHICLE #3 Thomas K. Atwood - Attorney at Law PAGE 23
24 13. SPOUSAL & CHILD SUPPORT PAID TO OTHERS: Not already deducted from pay statements 14. Other Support Payments to family members, etc Parents, siblings, elderly/disabled family members - all others than child and spousal support 15. OTHER REAL PROPERTY THAN RESIDENCE Mortgage payments on other properties: Real Estate Taxes: Property insurance: Maintenance, repairs and upkeep: HOA Dues: PLEASE ATTACH A SEPARATE PAGE IF YOU HAVE MORE THAN ONE PARCEL OF REAL ESTATE 16. OTHER EXPENSES: TOTAL MONTHLY EXPENSES: Thomas K. Atwood - Attorney at Law PAGE 24
25 LIST OF CREDITORS PLEASE LIST ALL CREDITORS COMPLETE WITH ADDRESSES INCLUDING ZIP CODE. CORRECT ADDRESSES WITH ZIP CODE ARE VERY IMPORTANT FOR PROPER NOTICE SO PLEASE BE ACCURATE AND COMPLETE. ALSO PLEASE PROVIDE AN ESTIMATE OF AMOUNT OWED AND ACCOUNT NUMBER IF KNOWN. IF AVAILABLE, PLEASE ATTACH THE 2 MOST RECENT STATEMENTS/BILLS FROM EACH CREDITOR. PLEASE INDICATE THE BASIS FOR THE DEBT: (Loan, credit line, credit card, services, consumer goods, etc.) AND WHETHER THE DEBT IS SECURED AND BY WHAT PROPERTY. PLEASE GIVE THE DATE(S) THE DEBT WAS INCURRED - DATE(S) MONEY WAS BORROWED (Please provide exact dates if debt incurred within the past three months) FOR CREDIT CARDS, PLEASE GIVE THE RANGE OF DATES THAT CHARGES WERE INCURRED ON THE CARD (Example - If you have a Visa card that has a balance left from charges made in 2009 and your last charge was in January of 2014, please indicate that the debt was incurred "2009 through Jan/2014") A good way to look at this is determine when the account was last at $0, which is the first date, and then when the last charge was made, which is the last date. PLEASE LIST ALL CO-SIGNERS AND PROVIDE A COPY OF THE ORIGINAL CONTRACT SHOWING COSIGNER LIAIBILITY : (Co-signers - Other parties who also signed the contract with your creditor) PLEASE INCLUDE EVERYONE THAT YOU OWE MONEY TO INCLUDING RELATIVES AND PERSONAL LOANS. IT IS IN YOUR BEST INTEREST TO LIST ALL CREDITORS AND IS REQUIRED UNDER BANKRUPTCY LAW. THESE CREDITORS WILL BE LISTED IN YOUR PETITION FOR BANKRUPTCY WHICH YOU WILL BE SIGNING UNDER PENALTY OF PERJURY. FAILURE TO LIST ALL CREDITORS WILL RESULT IN AN INCOMPLETE PETITION FOR BANKRUPTCY AND MAY AFFECT THE COST AND VALIDITY OF YOUR BANKRUPTCY. 1. NAME OF CREDITOR: Thomas K. Atwood - Attorney at Law PAGE 25
26 2. NAME OF CREDITOR: 3. NAME OF CREDITOR: Thomas K. Atwood - Attorney at Law PAGE 26
27 4. NAME OF CREDITOR: 5. NAME OF CREDITOR: Thomas K. Atwood - Attorney at Law PAGE 27
28 6. NAME OF CREDITOR: 7. NAME OF CREDITOR: Thomas K. Atwood - Attorney at Law PAGE 28
29 8. NAME OF CREDITOR: 9. NAME OF CREDITOR: Thomas K. Atwood - Attorney at Law PAGE 29
30 10. NAME OF CREDITOR: 11. NAME OF CREDITOR: Thomas K. Atwood - Attorney at Law PAGE 30
31 12. NAME OF CREDITOR: 13. NAME OF CREDITOR: Thomas K. Atwood - Attorney at Law PAGE 31
32 14. NAME OF CREDITOR: 15. NAME OF CREDITOR: Thomas K. Atwood - Attorney at Law PAGE 32
33 16. NAME OF CREDITOR: 17. NAME OF CREDITOR: Thomas K. Atwood - Attorney at Law PAGE 33
34 18. NAME OF CREDITOR: 19. NAME OF CREDITOR: Thomas K. Atwood - Attorney at Law PAGE 34
35 20. NAME OF CREDITOR: 21. NAME OF CREDITOR: PLEASE USE ATTACHMENTS IF YOU HAVE MORE CREDITORS PLEASE LIST ALL CREDITORS! Thomas K. Atwood - Attorney at Law PAGE 35
36 CREDIT REPORT BUREAUS - CONTACT INFORMATION The Fair and Accurate Credit Transactions Act (FACT) now allows you to obtain a free credit report from each major credit reporting bureau once per year. I urge you to get the free reports which are very useful in making certain you have listed all creditors. The free reports can be obtained via the internet at: or by phone: or by mail: Annual Credit Report Request Service P.O. Box Atlanta, GA Please PRINT out the credit reports and bring or mail them to my office, or save them to your hard drive and them directly to me at docs@tomlaw.com. If you prefer, I can obtain a tri-bureau merged report for you for a fee of $40 single, $60 for a couple. If you need to contact the credit bureaus directly, their contact information is below: 1. Experian P.O. Box 2104 Allen, TX Website: Phone: Equifax Credit Information Services, Inc P.O. Box Atlanta, GA Website: Phone: TransUnion Post Office Box 2000 Chester, PA Website: Phone: Sincerely, Thomas K. Atwood Thomas K. Atwood - Attorney at Law PAGE 36
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