BANKRUPTCY QUESTIONNAIRE Please complete this questionnaire and return it to the office before your first appointment. If you will spend the time to complete all items, you will provide us with the necessary background information to determine whether you and/or your spouse qualify for bankruptcy protection. All information provided will be held in strict confidence. 1. Please provide your full name, date and place of birth, and Social Security number: a. Name: b. Date of birth: c. Are you a citizen or permanent resident of the United States and the State of Florida: YES or NO (please circle answer) d. If Yes, how long have you been a citizen or resident of the U.S. e. Social Security number: f. What is your highest level of education: g. Where do you currently reside: h. Do you rent or own your home: i. Home telephone number: j. How long have you lived in your current residence? _ k. If less then 2 years please list previous address:
2. Are you currently employed? YES or NO (please circle answer) If No, please skip to question #4. 3. If you are employed, please provide the following income information: a. Employer name: b. Employer street address: c. Employer telephone number: d. Job title: e. Gross salary: f. Other sources of income: (pension, social security, disability, etc.) g. Average monthly income from all sources: 4. If married, please provide the following information for your spouse: a. Name: b. Date of birth: c. Is your spouse a citizen or permanent resident of the United States and the State of Florida: YES or NO (please circle answer) d. If Yes, how long have you been a citizen or resident of the U.S.? e. Spouse s Social Security number: 14211 COMMERCE WAY, SUITE 300, 2 MIAMI LAKES, FLORIDA 33016
f. Highest level of education: 5. Does your spouse reside with you? YES or NO (please circle answer) If No, please provide the following: a. Street address: b. City, State, and Zip: c. Residence telephone number: 6. If your spouse is employed, please complete the following regarding your spouse's employment. a. Employer: b. Street address: c. City, State, and Zip Code: d. Telephone number: e. Job title: f. Gross salary: g. Other sources of income: (pension, social security, disability, alimony, child support): h. Average total monthly income from all sources: 7. Have you or your spouse ever filed for bankruptcy before? YES or NO (please circle answer) If Yes, please bring copies of all related documents. If No, please skip to question #9 8. If Yes to question 7, when did you last file? Please provide the name of the attorney who represented you: 9. Have you or your spouse been involved in any litigation within the last 24 months? YES 3
or NO (please circle answer) If Yes, please bring copies of all related documents. If No, please skip to question #12. 10. If Yes to question 9, please provide the date the case was filed: 11. If Yes to question 9, please describe the nature and outcome of the suit and whether you were the plaintiff or defendant in the action: 12. Please provide the following financial information. a. Credit Card Name(s) Current Balance Account Number b. Secured Creditors (Car, Mtg) Current Balance Account Number c. Other debts (loans, judgment) Current Balance Account Number 4
13. Please list all real property you own: a. Address Current Balance Main, Second Home or Inv. 14. Please list all automobiles you own: a. Year/Make/Model Current Balance VIN Number 15. Please list all other property you own: (stocks, bonds, furniture, electronics, jewelry, tools, equipment or other) a. Type of property Current Balance Estimated Value 5
16. Please provide the reasons you are considering bankruptcy: (please use additional paper if necessary) 17. Please list all present bank accounts, IRA, 401k or Pension accounts: a. Bank Balance Type (IRA, Checking, Savings, CD) 18. Please list all your current household expenses: a. Utilities: 6
b. Telephone Service: c. Property Insurance: d. Property Taxes: e. HOA Fees: f. All other expenses: (school tuition, child support, alimony, medical expenses, etc.) g. Average monthly household expenses: 19. Have you been referred to our office by someone? If so, please indicate the name of the referring party: 20. Please attach a copy of your current driver's license. 21. Please identify any additional debts, matters or special circumstances you feel may be relevant to your bankruptcy: 7
IT IS ABSOLUTELY IMPERATIVE THAT YOU PROVIDE US WITH YOUR COMPLETE FINANCIAL AND ASSET INFORMATION AS THE FILING OF A BANKRUPTCY PETITION WHICH CONTAINS ANY MATERIAL MISREPRESENTATION IS PUNISHABLE BY FINE AND/OR IMPRISONMENT PURSUANT TO TITLE 18 U.S. CODE SECTIONS 152 AND 3571. PLEASE BE HONEST AND ACCURATE. I/We represent that the foregoing information is true and correct to the best of my knowledge and understand the potential consequences should I/We intentionally withhold or misrepresent the state of my assets before the court. Client Signature Print your name above Client Signature Print your name above 8