DEBTOR BANKRUPTCY QUESTIONNAIRE 1. Chapter: 7 11 13 Referred by: 2. Filing Status: Individual and unmarried Individual, married and living apart Individual, married and living together Joint and living together Joint and living apart If you are separated or divorced from your spouse, list his/her address: 3. Client(s) Name(s): FULL AND COMPLETE NAME, INCLUDING MIDDLE NAME: Mr./Mrs./Ms. DOB: Mr./Mrs./Ms. DOB: (state spouse's name whether or not he/she is filing too) Gender: Male Female Social Security No: a. (spouse)b. List any other names used in the last 6 years: a. b. Home Address: Mailing Address: (Only if different from home address) County: Phone: h:( ) a. w:( ) Email address: a. b. w:( ) b. Has debtor moved within last 2 years? Yes No If yes, state prior address(es) and dates of occupancy:: Page 1 of 26
4. Have you or your spouse ever filed Bankruptcy before? Yes No If yes, who filed, and provide the year filed, case number, chapter, which state, Judge's name, date dismissed/discharged. REAL PROPERTY, TIMESHARES, BURIAL PLOTS, RENTAL PROPERTIES JOINTLY HELD REAL PROPERTY OF ANY KIND BRING COPIES OF ANY AND ALL MORTGAGE STATEMENTS, DEEDS, TAX BILLS, ETC. DO YOU OWN A HOME? If NO, list the name and address of your landlord, the terms of your lease including the date you entered into the lease and the date it ends, or if you are renting month-to-month and the amount of rent. Landlord: Beginning Date: Address: Ending Date: Terms: Mo. Pmt. $ IF YES, PLEASE FILL OUT THE FOLLOWING ANSWERING EACH AND EVERY QUESTION. WE MUST HAVE AN ANSWER TO EACH QUESTION ASKED IN ORDER TO PREPARE THE BANKRUPTCY PETITION. Property Address: Purchase Date: / / Purchase Price: $ Current Value $ Owners: Have you made any significant improvements to your home since you purchased it? This DOES NOT include paint, wallpaper, carpeting, flooring, etc. This DOES include additions, finishing basement, pool, decks, patios, screened-in porches, etc. No Yes If yes, briefly describe the improvement and the total cost. Total cost of improvements: $ First Mortgage: COMPLETE THIS SECTION AND ATTACH MOST RECENT MORTGAGE STATEMENT Name of Mortgage Co.: Address of Mortgage Co.: Page 2 of 26
Telephone No. ( ) The month and year you obtained the loan?, 19 Original Loan Amount $ Account No. Interest Rate: % Balance $ Monthly Payment $ Late Charge $ Due Date / / Any co-owners or co-signors on the note? If so, list name, address and relationship to the debtor: Number of months delinquent Is Property in Foreclosure? Yes No If yes, date of sale:, 19 (please continue information on next page) If you have received any letters from your mortgage company or its attorney, please forward me copies of same. Should you receive any letters from them in the future, please forward them to me immediately. Name, address & ph. number of attorney for mortgage co: ( ) Second Mortgage: COMPLETE THIS SECTION AND ATTACH MOST RECENT MORTGAGE STATEMENT Name of Mortgage Co.: Address of Mortgage Co.: Telephone No. ( ) The month and year you obtained the loan?, 20 Original Loan Amount $ Account No. Interest Rate: % Balance $ Monthly Payment $ Late Charge $ Due Date / / Any co-owners or co-signors on the note? If so, list name, address and relationship to the debtor: Number of months delinquent Property in Foreclosure? Yes No If yes, date of sale:, 20 If you have received any letters from your mortgage company or its attorney, please forward me copies of same. Should you receive any letters from them in the future, please forward them to me immediately. Name, address & ph. number of attorney for mortgage co: ( ) Page 3 of 26
IF YOU OWN ANY ADDITIONAL REAL PROPERTY (such as rental properties) LIST THEM ON THE REVERSE SIDE INCLUDING ALL OF THE ABOVE INFORMATION. Homeowner Association: Name of Association: Address of Association.: Telephone No. ( ) Account No. Monthly Payment $ Due Date / / Number of months delinquent If you have received any letters from your association or its attorney, please forward me copies of same. Should you receive any letters from them in the future, please forward them to me immediately. Name, address & ph. number of attorney for homeowner association: ( ) Please provide like information regarding any and all other homes, burial plots, timeshares, rental properties, unimproved lots, jointly held property, etc. Remember to disclose information regarding ANY AND ALL PROPERTY that may have your name on the title or deed This includes inherited property that may not be in your name yet and that you may own with siblings, other relatives or persons. whether you live in it or use it or not!!
Car No.: 1: AUTOMOBILES - LIST ALL CARS TITLED IN YOUR NAME WHETHER YOU ACTUALLY DRIVE THEM OR NOT BE SURE AND ATTACH YOUR MOST RECENT CAR STATEMENT!! Year Make Model Mileage: 2DR 4DR List all options: Auto. 5 speed Date of purchase: / / Purchase Price $ Original Loan Amount $ No. of months delinquent Current Value of Vehicle $ Monthly Payment $ Years Financed: Balance of Loan: $ Interest Rate: % Late Charge $ Date due every month Account No. Who purchased vehicle: Husband, Wife or Both? Any co-signors? No Yes If yes, who? Lender's Name Lender's Address Ph. number (if known) ( ) Car No.: 2: Year Make Model Mileage: 2DR 4DR List all options: Auto. 5 speed Date of purchase: / / Purchase Price $ Original Loan Amount $ No. of months delinquent Current Value of Vehicle $ Monthly Payment $ Years Financed: Balance of Loan: $ Interest Rate: % Late Charge $ Date due every month Account No. Who purchased vehicle: Husband, Wife or Both? Any co-signors? No Yes If yes, who?
Lender's Name Lender's Address Ph. number (if known) ( ) Car No.: 3: Year Make Model Mileage: 2DR 4DR List all options: Auto. 5 speed Date of purchase: / / Purchase Price $ Original Loan Amount $ No. of months delinquent Current Value of Vehicle $ Monthly Payment $ Years Financed: Balance of Loan: $ Interest Rate: % Late Charge $ Date due every month Account No. Who purchased vehicle: Husband, Wife or Both? Any co-signors? No Yes If yes, who? Lender's Name Lender's Address Ph. number (if known) ( ) LIST ALL VEHICLES THAT HAVE BEEN PAID OFF TOO.
List value of the following and describe, if appropriate: ASSETS: PERSONAL PROPERTY QUESTIONS 1. How much cash do you have on hand? $ 2. List ALL (SOLELY OR JOINTLY HELD) checking and savings accounts, cert. of deposits, credit unions, etc: PROVIDE COPIES OF LAST 3 MONTHS OF BANK STATEMENTS FROM ALL OPEN ACCOUNTS WHETHER THEY HAD BALANCES OR NOT. Name of institution/location Account No. Balance: $ Type of account: Joint account? Yes No Name of institution/location Account No. Balance: $ Type of account: Joint account? Yes No Name of institution/location Account No. Balance: $ Type of account: Joint account? Yes No 3. Do you have any security deposits with landlords, public utilities, telephone companies, etc? If so, state the name of the person holding the deposit and the amount of the deposit: DOES ANY CREDIT UNION HOLD THE TITLE TO ANY CAR OR DEED TO ANY PROPERTY? If so, please explain:
4. HOUSEHOLD GOODS AND FURNISHINGS: Please check off all household goods that you own. If you own more than one of these items, place a number on the right side of the item. List the value of the property. The value should be determined by the price you would buy or sell the property for at a EXAMPLE: YARD SALE VALUE!!!. NUMBER OF NUMBER OF ITEM ITEMS OWNED VALUE ITEM ITEMS OWNED VALUE LIVING ROOM: COUCH 1 $ 50 LOVE SEAT $ CHAIR $ TABLES $ LAMPS 2 $ 20 TV 1 $ 200 STEREO 1 $ 100 VCR $ $ START HERE: NUMBER OF NUMBER OF ITEM ITEMS OWNED VALUE ITEM ITEMS OWNED VALUE LIVING ROOM: COUCH $ LOVE SEAT $ CHAIR $ TABLES $ LAMPS $ TV $ STEREO $ $ $ TOTAL LIVING ROOM VALUE: $ DINING ROOM: TABLE $ CHAIRS $ CHINA CABINET $ BUFFET $ TOTAL DINING ROOM VALUE: $ KITCHEN: TABLE $ CHAIRS $
MISC. COOKING & $ $ EATING UTENSILS $ TOTAL KITCHEN ROOM VALUE: $ DEN: COUCH $ LOVE SEAT $ CHAIR $ TABLES $ LAMPS $ TV $ STEREO $ $ $ TOTAL DEN ROOM VALUE: $ BEDROOM #1: BED $ DRESSER $ CH/DWR $ TABLES $ LAMPS $ TV $ STEREO $ $ TOTAL BEDROOM #1 ROOM VALUE: $ BEDROOM #2: BED $ DRESSER $ CH/DWR $ TABLES $ LAMPS $ TV $ STEREO $ $ TOTAL BEDROOM #2 ROOM VALUE: $ BEDROOM #3: BED $ DRESSER $ CH/DWR $ TABLES $ LAMPS $ TV $ STEREO $ $ TOTAL BEDROOM #3 ROOM VALUE: $ BEDROOM #4: BED $ DRESSER $ CH/DWR $ TABLES $ LAMPS $ TV $
STEREO $ $ TOTAL BEDROOM #4 ROOM VALUE: $ BASEMENT: COUCH $ LOVE SEAT $ CHAIR $ TABLES $ LAMPS $ TV $ STEREO $ $ TOTAL BASEMENT VALUE: $ MISC: Office $ $ Equipment $ $ (specify) Computer $ $ Equipment $ $ (specify) Camera $ $ Equipment $ $ (specify) Exercise $ $ Equipment $ $ (specify) Art Objects $ $ Antiques $ $ Coin $ $ Collection TOTAL MISCELLANEOUS VALUE: $
5. WEARING APPAREL: Please check off all the clothing that you own and the number of each item that you own. List the value of the clothing. The value should be determined by the price you would buy or sell the property for at a YARD SALE VALUE. EXAMPLE: NUMBER OF NUMBER OF ITEM ITEMS OWNED VALUE ITEM ITEMS OWNED VALUE Suits 5 $100 Skirts 8 $250 MALE CLOTHING: FEMALE CLOTHING: NUMBER OF NUMBER OF ITEM ITEMS OWNED VALUE ITEM ITEMS OWNED VALUE Suits Suits Sport Coats Blazers Shirts Skirts Pants Pants Sweaters Blouses Shoes Dresses Coats Sweaters Jackets Furs Rings Jackets Watches Coats Bracelets Shoes Necklaces Purses Watches Necklaces Bracelets Rings Broaches Earrings Total: $ Total: $
6. List all firearms and sports, photographic and other hobby equipment and give value of each. 7. Do you have any life insurance policies with cash value? Yes No If yes, state with whom you have these policies, the face value of the policy, cash value of the policy, and whether or not they are term policies. 8. Do you receive annuities. Yes No If yes, itemize, name each issuer and value. 9. Do you have any interest in IRA, ERISA, Keogh, Thrift Savings or other pension, profit sharing or retirement plans? If yes, itemize and give value/balance of each: Please provide copies of current statements. 10. Do you own any stock and interests in incorporated and unincorporated business? If yes, itemize and give value. 11. Do you have any interests in partnerships or joint ventures? If yes, itemize and give value. 12. Do you own any government and corporate bonds and other negotiable and non-negotiable instruments? If yes, list them and give value. 13. Any accounts receivables? In other words, does anyone owe you any money? If yes, list them and the value. 14. Any alimony, maintenance, support, or property settlements to which you are entitled. If yes, explain and give value of support. 15. Federal tax refunds received this year. $ Federal tax refunds due this year. $ State tax refunds received this year. $ State tax refunds due this year. $ 16. Do you own any patents, copyrights, or other intellectual property? Give value and particulars. 17. Any licenses, franchises, and other general intangibles? Give value and particulars.
18. Do you own any trailers, tractors or other vehicles and accessories other than those listed under "Automobiles". If so, explain and give value of each. 19. Do you own any boats, motors and/or accessories? If so, list make, model, year and value. Do you have a lien on your boat? Yes No. If yes, list them under the "creditor" section. 20. Do you own any aircraft and accessories? If yes, explain and give value. 21. Do you own any machinery, fixtures, equipment, and supplies used in your business? If yes, explain and give value of each. 22. List all animals you own and the value of each animal. 23. Do you grow any crops? Give particulars. 24. Do you own any farming equipment and implements? If yes, explain and give value of each. 25. Do you own any farming supplies, chemicals and feed? If yes, explain and give value of each. 26. Do you own any other personal property or have any claims of any kind not already listed? If yes, itemize and give value of each. 27. Are you or have you been a plaintiff or defendant, in any civil, criminal, municipal, administrative, county, state or federal action and/do you have any claims or lawsuits against anyone for money owed to you such as a personal injury or workman s compensation claims? if so, please explain:
CREDITOR INFORMATION ATTACH YOUR ORIGINAL BILLS AND SKIP THIS SECTION!!! ALSO BRING NOTICES FROM COLLECTION AGENCIES!! DON T FORGET YOUR ANY RETIREMENT LOAN STATEMENTS!! Please list everyone you owe money to including: credit cards, personal loans, secured loans, credit union loans, magazine subscriptions, medical bills, insufficient checks, etc. All creditors must have complete addresses and account numbers. * YOU MAY ATTACH COPIES OF RECENT CREDIT CARD STATEMENS IN LIEU OF FILING OUT BELOW. EXAMPLE: CREDITOR NAME ACCOUNT # MONTHLY BALANCE ITEMS TYPE OF & ADDRESS DATE OPENED PAYMENT PURCHASED ACCOUNT (choose 1) Sears 123-456-789 $20 $1,200 washer/dryer Joint 7023 Albert Pick Rd. 09/88 misc. clothing Husband Greensboro, NC 27409 necklace Wife CREDITOR NAME ACCOUNT NO. MONTHLY BALANCE ITEMS TYPE & ADDRESS & DATE OPENED PAYMENT PURCHASED ATTACH ORIGINAL BILLS AND SKIP THIS SECTION
If more than 3 executory contracts, attach additional sheets EXECUTORY CONTRACTS Name and Address of Party Description of Contract Contract is a lease for NONRESIDENTIAL real property Government Contact No., if any: Surrender property reject lease Name and Address of Party Description of Contract Contract is a lease for NONRESIDENTIAL real property Government Contact No., if any: Surrender property reject lease Name and Address of Party Description of Contract Contract is a lease for NONRESIDENTIAL real property Government Contact No., if any: Surrender property reject lease
CODEBTORS If more than 3 codebtors, attach additional sheets Name and Address of Codebtor Creditor to whom Codebtor may be liable Other names by which Codebtor is known Name and Address of Codebtor Creditor to whom Codebtor may be liable Other names by which Codebtor is known Name and Address of Codebtor Creditor to whom Codebtor may be liable Other names by which Codebtor is known
BUDGET QUESTIONS YOU AND YOUR SPOUSE OR ANY OTHER WORKING PERSON IN THE HOUSEHOLD (WHETHER OR NOT HE/SHE IS FILING TOO) MUST ATTACH AND PROVIDE AT LEAST SIX MONTHS OF CHECK STUBS FROM YOUR FULL AND/OR PART TIME JOB, ALONG WITH COPIES OF DOCUMENTATION VERIFYING OTHER INCOME SUCH AS RETIREMENT OR SOCIAL SECURITY CHECKS OR STATEMENTS, LEASES, CHILD SUPPORT ORDERS OR AGREEMENTS: Is ANYONE IN THE HOUSEHOLD EMPLOYED? YES NO How often is each person paid? ATTACH 6 MONTHS OF MOST RECENT PAYSTUBS DEBTOR: monthly weekly every two weeks SPOUSE: monthly weekly every two weeks twice a month other (explain) twice a month other (explain) OTHER HOUSEHOLD WORKING ADULT: monthly weekly every two weeks twice a month other (explain) Employer's Name: Address: Phone( ) Employee Owner Debtor's occupation & nature of business: Dates of Employment: Annual gross income (rounded to nearest thousand): ATTACH ALL W-2 S AND SKIP THIS PART. Year-to-Date: Last year - Prior Year - Employer Amount $ Employer Amount $ Employer Amount $ NOTE: IF YOU LIVE WITH YOUR SPOUSEOR ANY OTHER WORKING HOUSEHOLD PERSON, THIS INFORMATION MUST BE PROVIDED WHETHER THE SPOUSE WILL BE FILING FOR BANKRUPTCY PROTECTION OR NOT. THE LAST MONTHS PAYSTUBS MUST ALSO BE PROVIDED ALONG WITH INFORMATION REGARDING ANY OTHER INCOME THAT SPOUSE MAY HAVE.
Is debtor's spouse (or other working household member) currently employed: Yes No If Yes, state the Employer's Name: Address: Phone( ) Employee Owner Please also state the occupation & nature of business: Dates employed: Annual gross income: ATTACH ALL W-2 S AND SKIP THIS PART. Year-to-Date: Last year - Prior Year - Employer Amount $ Employer Amount $ Employer Amount $ Please list any and all other other sources of all household income? (Annuities, social security, disability, rental income, child support, alimony, etc). Remember to attach verification. If yes, list the following:
LIST ALL DEPENDENTS: (children, parents, etc.) Name Age Relationship 1. 2. 3. 4. 5. 6.
EXPENDITURES (Individuals Only) Rent or Mortgage Insurance Included? (Yes/No) Taxes Included? (Yes/No) Utilities Electricity & Heat Water & Sewer Telephone Other (specify): Home Maintenance Food Clothing Laundry & Dry Cleaning Medical & Dental Expenses Transportation (Do NOT include car payments) Recreation Insurance Homeowners Life Health Auto Taxes Other (Specify): Installment Payments (not in plan) Auto Other (Specify): Other (Specify): Alimony, maintenance, support Payments for dependents Business expenses **(attach detailed statement) Other Expenses (specify): Charitable Contributions
Expenditures Page Inserted Here
STATEMENT OF FINANCIAL AFFAIRS 1. List any and all individual creditors who were paid a total of more than $600 within the last 90 days. Provide address, date of payment, amount paid and amount still owing. (Including rent, mortg., credit cards, car pmts., etc.) 2. List all property that has been repossessed by any creditor, attached, garnished, seized, sold at a foreclosure sale, transferred through a deed in lieu of foreclosure or returned to the seller, within the last year. Provide date, value of property, name and address of creditor and account no. 3. List all gifts or charitable contributions made within the last year worth more than $200.00. State the amount/value donated, name of person/organization, address and relation to debtor. 4. List all losses from fire, theft or other casualty or gambling within the last year. Include circumstances, date of loss, value of property and if covered by insurance. 5. List all other property that you have transferred, refinanced, given away or sold within the last three years, the amount of the sale, date of sale, the name and address of party to whom it was sold. Also include changes in the ownership any of real property, including persons added or deleted and changes in title ownership. (i.e. tenants in common, tenants by the entirety, joint tenants, etc.) 6. Have you closed or transferred any bank accounts within the last year? If so, list when and where they were closed or transferred from, where they were transferred to, account no., and how much was in the account at the time you closed it, even if the balance was zero or in the negative.. 7. List each safe deposit box or other box or depository in which you have or had securities, cash, or other valuables within the last year. Include the name and address of the bank/institution, names and addresses
to those with access to box, and a description of contents. 8. List all property owned by another person in your possession. Include name and address of owner, value and location of property. This includes any bank account, house, car or other property. 9. List the name and address of all businesses which you were involved with as an officer, director, or partner within the last two years whether or not it is or was profitable or is currently closed.. Include nature of business, beginning date and ending date, % of interest. 10. List all bookkeepers and accountants you have employed within the last six years. Include addresses and dates for services rendered. ADDITIONAL COMMENTS/ ISSUES/CONCERNS:
CLIENT CERTIFICATION OF QUESTIONNAIRE COMPLETION: I swear or affirm that I have fully and completely read this questionnaire and have provided The Kelsey Law Firm with all information requested and/or known to me to the best of my ability. The documents requested are attached as follows: Check all that apply: Information regarding any and all prior bankruptcy filings. Information regarding all prior residences over the past 2 years. Information regarding any and all lawsuits or other legal proceedings for which I am or have been a plaintiff, defendant or other party (past and present). Copies of all original (and most recent) mortgage statements (including payoff information), deeds, real property tax documents or other documents relating to any land, lot, timeshare, burial plot, rental property, etc. (hold solely or with any other person or inherited to me) Information regarding any pending foreclosure action. Copies of any and all W-2 s, signed federal and state tax returns, with all supporting schedules, paystubs and verification of any and all income for any person in the household. Copies of all automobile statements, including payoff information. Last 3 months of all banking statements, held solely by me or jointly with any other person(s). Fair Market Value information from www.zillow.com for real property or from www.nadaguides.com or www.kbb.com, for any and all automobiles. Payoff balances for any and all retirement loans. Information regarding any tax liabilities.
The information provided is given to the best of my knowledge, information and belief. I also understand that I must advise The Kelsey Law Firm of any information that may affect my current answers, including any updates and/or necessary changes. I also understand that updated information will be required if my case is not filed within thirty (30) days and that there will be an additional charge for the review and update of my file. I understand that my case will not be filed until all information is received for a full and complete filing unless agreed upon otherwise. Finally, I hold The Kelsey Law Firm harmless from any negative action(s) and/or result(s) from the withholding of information that was requested on this document along with any other information requested in the bankruptcy section of The Kelsey Law Firm s website along with any liability from any late filing due because requested documentation was not timely provided. Debtor Co-Debtor Date: Date: