BANKRUPTCY CLIENT QUESTIONNAIRE

Thank you for contacting Yusufov Law Firm PLLC for legal assistance with respect to your legal matter.  The purpose of this Questionnaire is to gather the information that we need to properly prepare your bankruptcy case.  Please complete all sections of this Questionnaire—returning the Questionnaire incomplete will delay the filing of your case.  Please provide us with emergency phone or address contact information.  Please also provide us with a valid email address.  

Under the law, you must list each and every debt, including debts to friends and relatives.   If you need more space, please use the back or photocopy the page of boxes.  Please also remember to list every creditor to whom you are obligated.  This means, for example, that if you have co-signed for your nephew's car loan, that car lien-holder is your creditor.  Similarly, you should list debts even if you think the creditor has written off the loan or if you think that someone else may pay the bill in the future (i.e. a medical bill that may be covered by insurance).  YOU MUST PROVIDE A COMPLETE ADDRESS FOR EVERY CREDITOR YOU LIST.  Please provide us with the correspondence address for each creditor rather than the billing address.

Please provide us COPIES OF PAY STUBS and proof of household income for the 6 months prior to filing.  Please also provide us with BANK STATEMENTS for the past 3 months.

We will also need copies of TAX RETURNS for the past two years.  If there are any years in the past 15 years when you did not file tax returns, please let us know that as well.

One of the most important items of information that you can provide relates to whether a debt is "secured" or "unsecured."  A "secured" debt is a debt that is backed by collateral, such as a house, car or even household items.  By contrast, an "unsecured" debt is backed only by your signature.  Examples of unsecured debts are credit card bills and medical bills.  Please note that many finance companies ask you to list household goods at the time you obtain your loan.  This usually means that you may have given the finance company a security interest in your property.

Finally, when providing a list of your property, please list all property to which you hold legal title, even if somebody else is in possession of the property.  Such a situation is particularly common with vehicles which are used by friends or family members, but for which you are the owner of record (i.e. listed on the title).

Again, thank you for choosing Yusufov Law Firm PLLC.  We will make every effort to make sure that your experience as our client is a pleasant one.
Mailing Address:	Yusufov Law Firm PLLC
5151 E. Broadway, Suite 1600
Tucson, Arizona 85711
(520) 745-4429
info@yusufovlaw.com
www.YLFbankruptcy.com

Client Questionnaire
Section 1 - Basic Information
Part A. Name and Address
Name:                                                                
Have you used any other names in the past eight years?   No    Yes
If yes, please list other names used:
Have you used any business names or Employer Identification Numbers (EIN) in the last 8 years?
	If yes, please list business names and/or EINs used:

Telephone Numbers\Email address:
Home:                                        
Work:                                        
Cell:                                        
Email:                                                                
Social Security Number:                      -               -                            
Driver's License Number:                                                                     Expiration Date:                                  State:              
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
If you answered no to either of the questions above, please list your previous address:
Address:                                                                
City:                                                             State:                 Zip:                             County:                              
If you have a different mailing address, please list:
Mailing Address:                                                                
City:                                                             State:                 Zip:                             County:                              

Marital Status:	 Never Married	 Married and living together      Widowed
	 Married and living apart	 Divorced
Part B. Name and Address of Spouse
If you are filing jointly with your spouse, fill in the following information about your spouse:
Name:                                                                
Has your spouse used any other names in the past 8 years?   No    Yes
If yes, please list other names used:
Has your spouse used any business names or Employer Identification Numbers (EIN) in the last 8 years?
	If yes, please list business names and/or EINs used:

Telephone Numbers\Email address:
Home:                                        
Work:                                        
Cell:                                        
Email:                                                                
Social Security Number:                      -               -                            
Driver's License Number:                                                                     Expiration Date:                                  State:              
Date of Birth:                                        

If your spouse lives at a different address, please list:
Address:                                                                
City:                                                             State:                 Zip:                             County:                              
Has your spouse lived at this address for at least 180 days?   No    Yes
Has your spouse lived at this address for at least 730 days (2 years)?   No    Yes
If you answered no to either of the questions above, please list your spouse's previous address:
Address:                                                                
City:                                                             State:                 Zip:                             County:                              
If your spouse has a different mailing address, please list:
Mailing Address:                                                                
City:                                                             State:                 Zip:                             County:                              
Part C. Prior and/or Pending Bankruptcy Cases
Have you filed a bankruptcy case in the last 8 years?    No    Yes
If yes, in which district of which state was the case filed?                                                                 
Case Number:                                                                 
Date Filed:                                                                
Date Discharged:                                                                 
Was the case dismissed (you did not complete the bankruptcy)?  No  Yes
If so, what date was it dismissed?                                                                 
Are any bankruptcy cases pending or being filed by your spouse, a business partner, or an affiliate?    No    Yes
If yes, name of debtor:                                                                 
Relationship to you:                                                                 
Case Number:                                                                 
Date Filed:                                                                
District (If known):                                                                 
Part D. Debtors Who Reside as Tenants of Residential Property
Do you have an eviction pending against you?   No    Yes
If yes, please provide your landlord's name and address:
Name:                                                                
Address:                                                                
City:                                                                 State:                 Zip:                             
Part E. Business Owned as a Sole Proprietor
Are you the sole proprietor of a full- or part-time business?
If yes, please provide the name and location of the business:
Name of business:                                                                
Address:                                                                
City:                                                                 State:                 Zip:                             

Description of business:

Part F. Hazardous Property or Property That Needs Immediate Attention
Do you own or have any property that needs immediate attention or that poses or is alleged to pose a threat of imminent and identifiable harm to public health or safety?   No    Yes
If yes, please describe the hazard:
If immediate attention is needed, why is it needed?
Where is the property? Address:                                                                 
City:                                                                  State:                  Zip:                             

Section 2 - Property (Schedule A/B)
Separately list and describe assets in each category below. List an asset only once. If an asset fits in more than one category, list the asset in the category where you think it fits best. If more space is needed, attach a separate page to this questionnaire.
Part A. Residence, Building, Land, Other Real Estate
Address and Description of Property	List all mortgages, home equity loans and other liens against the property:
Please provide details requested below.	Estimated Value of Property	Owned by:
You, your spouse, both you and your spouse, you and at least one person other than your spouse.	If you are not the only owner: 
Please enter the % of the property you own.	Office Use Only
Exemptions?	
Address:

What is the property? Check all that apply.

 Single-family home
 Duplex or multi-unit building
 Condominium or cooperative
 Manufactured or mobile home
 Land
 Investment property
 Timeshare
 Other:
	Who issued the mortgage, lien or loan? (Name and Address)

What is the amount of the mortgage, lien or loan?

What is your current interest rate on the loan?

What is your monthly payment?

Does payment include taxes and/or insurance?   No    Yes
How many payments are left?
		 You
 Spouse
 Joint
 Other: 			
Address:

What is the property? Check all that apply.

 Single-family home
Duplex or multi-unit building
 Condominium or cooperative
 Manufactured or mobile home
 Land
 Investment property
 Timeshare
 Other 
	Who issued the mortgage, lien or loan? (Name and Address)

What is the amount of the mortgage, lien or loan?

What is your current interest rate on the loan?

What is your monthly payment?

Does payment include taxes and/or insurance?   No    Yes
How many payments are left?
		 You
 Spouse
 Joint
 Other:			

Part B. Cars, Vans, Trucks, Tractors, SUVs, Motorcycles, RVs, Watercraft, Aircraft, Motor Homes, ATVs, Other Vehicles

Type of Property	Do you own this type of property?	Description	Value of Property	Owned by:
You, your spouse, both you and your spouse, you and at least one person other than your spouse.	Office Use Only
Exemptions?	
Vehicle #1	  No

  Yes	Year:                             
Make:                                                   
Model:                                                   
Mileage:                                                  

Other Information:
		 You
 Spouse
 Joint
 Other: 		
Vehicle #2	  No

  Yes	Year:                             
Make:                                                   
Model:                                                   
Mileage:                                                  

Other Information:
		 You
 Spouse
 Joint
 Other: 		
Vehicle #3	  No

  Yes	Year:                             
Make:                                                   
Model:                                                   
Mileage:                                                  

Other Information:
		 You
 Spouse
 Joint
 Other: 		
Watercraft/Aircraft/Motor Homes/ATVs/Other (list year, make, and model)	  No

  Yes			 You
 Spouse
 Joint
 Other:

Part C. Personal and Household Items

Type of Property	Do you own this type of property?	Description	Value of Property	Owned by:
You, your spouse, both you and your spouse, you and at least one person other than your spouse.	Office Use Only
Exemptions?	
Household Goods and Furnishings (Major appliances, furniture, linens, china, kitchenware, etc.)
(Break down by item and give value for each item)	  No

  Yes			 You
 Spouse
 Joint
 Other:
		
Electronics (TVs, stereos, computers, game consoles, tablets, iPods, mobile phones, etc.)	  No

  Yes			 You
 Spouse
 Joint
 Other:
		
Collectibles of value (art, paintings, prints, memorabilia, antiques, stamp/coin/card collections, etc.)	  No

  Yes			 You
 Spouse
 Joint
 Other:
		
Sports, photo, exercise, and other hobby equipment; musical instruments	  No

  Yes			 You
 Spouse
 Joint
 Other:
		
Firearms, ammunition, and related equipment	  No

  Yes			 You
 Spouse
 Joint
 Other:
		
Clothing (everyday clothes, furs, leather coats, designer wear, shoes, accessories)	  No

  Yes			 You
 Spouse
 Joint
 Other:
		
Jewelry	  No

  Yes			 You
 Spouse
 Joint
 Other:
		
Pets/non-farm animals	  No

  Yes			 You
 Spouse
 Joint
 Other:
		
Health aids and all other household items not listed	  No

  Yes			 You
 Spouse
 Joint
 Other:

Part D. Financial Assets

Type of Property	Do you own this type of property?	Description	Value of Property	Owned by:
You, your spouse, both you and your spouse, you and at least one person other than your spouse.	Office Use Only
Exemptions?	
Cash (spare change/money in your purse or wallet, cash not in accounts)	  No

  Yes			 You
 Spouse
 Joint
 Other:
		
Checking account #1 (list name(s) on account, bank name, and account number)	  No

  Yes			 You
 Spouse
 Joint
 Other:
		
Checking account #2 (list name(s) on account, bank name, and account number)	  No

  Yes			 You
 Spouse
 Joint
 Other:
		
Savings account #1 (list name(s) on account, bank name, and account number)	  No

  Yes			 You
 Spouse
 Joint
 Other:
		
Savings account #2 (list name(s) on account, bank name, and account number)	  No

  Yes			 You
 Spouse
 Joint
 Other:
		
Certificate of deposit (list name(s) on account, bank name, and account number)	  No

  Yes			 You
 Spouse
 Joint
 Other:
		
Other financial account #1 (list name(s) on account, bank name, and account number)	  No

  Yes			 You
 Spouse
 Joint
 Other:
		
Other financial account #2 (list name(s) on account, bank name, and account number)	  No

  Yes			 You
 Spouse
 Joint
 Other:
		
Other financial account #3 (list name(s) on account, bank name, and account number)	  No

  Yes			 You
 Spouse
 Joint
 Other:
		
Other financial account #4 (list name(s) on account, bank name, and account number)	  No

  Yes			 You
 Spouse
 Joint
 Other:
		
Bonds, mutual funds, and publicly traded stocks	  No

  Yes			 You
 Spouse
 Joint
 Other:
		
Non-publicly traded stocks and interests in businesses, corporations, LLCs, partnerships, and joint ventures (list % of ownership)	  No

  Yes			 You
 Spouse
 Joint
 Other:
		
Government and corporate bonds and instruments (including U.S. Savings Bonds)	  No

  Yes			 You
 Spouse
 Joint
 Other:
		
Retirement, pension, or profit-sharing plan #1 (IRA, 401(k), 403(b), thrift savings account, or other pension or profit-sharing plan) (list type of plan and where the account is held)	  No

  Yes			 You
 Spouse
 Joint
 Other:
		
Retirement, pension, or profit-sharing plan #2 (IRA, 401(k), 403(b), thrift savings account, or other pension or profit-sharing plan) (list type of plan and where the account is held)	  No

  Yes			 You
 Spouse
 Joint
 Other:
		
Retirement, pension, or profit-sharing plan #3 (IRA, 401(k), 403(b), thrift savings account, or other pension or profit-sharing plan) (list type of plan and where the account is held)	  No

 Yes			 You
 Spouse
 Joint
 Other:
		
Security deposits (typically with landlord or utility) (list holder)	  No

  Yes			 You
 Spouse
 Joint
 Other:
		
Prepayments (prepaid rent, layaway, gift cards, etc.)	  No

  Yes			 You
 Spouse
 Joint
 Other:
		
Annuities (list company)	  No

  Yes			 You
 Spouse
 Joint
 Other:
		
Education IRA, Sec. 529 or Sec. 530 account, state tuition plan	  No

  Yes			 You
 Spouse
 Joint
 Other:
		
Trusts, life estates, future, and equitable interests in property or assets	  No

  Yes			 You
 Spouse
 Joint
 Other:
		
Patents, copyrights, trademarks, trade secrets, and other intellectual property	  No

  Yes			 You
 Spouse
 Joint
 Other:
		
Licenses, franchises, and other general intangibles	  No

  Yes			 You
 Spouse
 Joint
 Other:
		
Tax refunds owed to you (list years due)	  No

  Yes			 You
 Spouse
 Joint
 Other:
		
Alimony and child support	  No

  Yes			 You
 Spouse
 Joint
 Other:
		
Other amounts someone owes you (unpaid wages, disability benefits, sick pay, vacation pay, workers' compensation, unpaid loans made by you, etc.)	  No

  Yes			 You
 Spouse
 Joint
 Other:
		
Cash value of insurance policies (whole or universal life, health, disability, HSA, etc.) (list insurance company and beneficiary)	  No

  Yes			 You
 Spouse
 Joint
 Other:
		
Inheritances, estate distributions, and death benefits	  No

  Yes			 You
 Spouse
 Joint
 Other:
		
Personal injury claims or awards	  No

  Yes			 You
 Spouse
 Joint
 Other:
		
Lawsuits or claims against anyone for anything	  No

  Yes			 You
 Spouse
 Joint
 Other:
		
All other claims or rights to sue someone	  No

  Yes			 You
 Spouse
 Joint
 Other:
		
Any other financial asset not listed	  No

  Yes			 You
 Spouse
 Joint
 Other:

Part E. Business-Related Assets

Type of Property	Do you own this type of property?	Description	Value of Property	Owned by:
You, your spouse, both you and your spouse, you and at least one person other than your spouse.	Office Use Only
Exemptions?	
Accounts receivable or commissions earned (list)	  No

  Yes			 You
 Spouse
 Joint
 Other:
		
Office equipment, furnishings, and supplies (list)	  No

  Yes			 You
 Spouse
 Joint
 Other:
		
Machinery, fixtures, equipment, business supplies, and tools of your trade (list)	  No

  Yes			 You
 Spouse
 Joint
 Other:
		
Business inventory (list)	  No

  Yes			 You
 Spouse
 Joint
 Other:
		
Interests in partnerships or joint ventures (name and type of business, % interest)	  No

  Yes			 You
 Spouse
 Joint
 Other:
		
Customer and mailing lists	  No

  Yes			 You
 Spouse
 Joint
 Other:
		
Other business-related property not already listed	  No

  Yes			 You
 Spouse
 Joint
 Other:

Part F. Farm and Commercial Fishing-Related Property

Type of Property	Do you own this type of property?	Description	Value of Property	Owned by:
You, your spouse, both you and your spouse, you and at least one person other than your spouse.	Office Use Only
Exemptions?	
Farm animals (livestock, poultry, farm-raised fish, etc.)	  No

  Yes			 You
 Spouse
 Joint
 Other:
		
Crops (growing or harvested)	  No

  Yes			 You
 Spouse
 Joint
 Other:
		
Farm and commercial fishing equipment, implements, machinery, fixtures, and tools of trade (list)	  No

  Yes			 You
 Spouse
 Joint
 Other:
		
Farm and commercial fishing supplies, chemicals, and feed (list)	  No

  Yes			 You
 Spouse
 Joint
 Other:

Part G. Miscellaneous

Type of Property	Do you own this type of property?	Description	Value of Property	Owned by:
You, your spouse, both you and your spouse, you and at least one person other than your spouse.	Office Use Only
Exemptions?	
All other property of any kind not previously listed	  No

  Yes	

		 You
 Spouse
 Joint
 Other:

Section 3 - Debts (Schedule D/E/F)
Part A. Debts Secured by Property
Please list below all debts that you owe OR that creditors claim you owe that are secured by property.
Type of Debt	Creditor Information	Property Information:	Person(s) Responsible/Codebtor	Do you dispute the debt?	Office Use Only	
Home loan and/or mortgage	1. Amount Owed (amount of claim):

2. Creditor Name and Address:

3. Account Number, if any:

4. Date/range of dates when debt was incurred:

5. Contact person's name and address if different:

	1. Describe property:

2. Monthly payment amount:

3. Number of payments remaining:

	Who owes the debt?

 Self

 Spouse

 Joint

 Other:

Is there a codebtor or cosigner on this loan?

  No

  Yes
If yes, please provide name and address:

	  No

  Yes		
Home loan and/or mortgage	1. Amount Owed (amount of claim):

2. Creditor Name and Address:

3. Account Number, if any:

4. Date/range of dates when debt was incurred:

5. Contact person's name and address if different:

	1. Describe property:

2. Monthly payment amount:

3. Number of payments remaining:

	Who owes the debt?

 Self

 Spouse

 Joint

 Other:

Is there a codebtor or cosigner on this loan?

  No

  Yes
If yes, please provide name and address:

	  No

  Yes		
Home loan and/or mortgage	1. Amount Owed (amount of claim):

2. Creditor Name and Address:

3. Account Number, if any:

4. Date/range of dates when debt was incurred:

5. Contact person's name and address if different:

	1. Describe property:

2. Monthly payment amount:

3. Number of payments remaining:

	Who owes the debt?

 Self

 Spouse

 Joint

 Other:

Is there a codebtor or cosigner on this loan?

  No

  Yes
If yes, please provide name and address:

	  No

  Yes		
Home loan and/or mortgage	1. Amount Owed (amount of claim):

2. Creditor Name and Address:

3. Account Number, if any:

4. Date/range of dates when debt was incurred:

5. Contact person's name and address if different:

	1. Describe property:

2. Monthly payment amount:

3. Number of payments remaining:

	Who owes the debt?

 Self

 Spouse

 Joint

 Other:

Is there a codebtor or cosigner on this loan?

  No

  Yes
If yes, please provide name and address:

	  No

  Yes		

Car loans	1. Amount Owed (amount of claim):

2. Creditor Name and Address:

3. Account Number, if any:

4. Date/range of dates when debt was incurred:

5. Contact person's name and address if different:

	1. Describe property:

2. Monthly payment amount:

3. Number of payments remaining:

	Who owes the debt?

 Self

 Spouse

 Joint

 Other:

Is there a codebtor or cosigner on this loan?

  No

  Yes
If yes, please provide name and address:

	  No

  Yes		
Car loans	1. Amount Owed (amount of claim):

2. Creditor Name and Address:

3. Account Number, if any:

4. Date/range of dates when debt was incurred:

5. Contact person's name and address if different:

	1. Describe property:

2. Monthly payment amount:

3. Number of payments remaining:

	Who owes the debt?

 Self

 Spouse

 Joint

 Other:

Is there a codebtor or cosigner on this loan?

  No

  Yes
If yes, please provide name and address:

	  No

  Yes		

Car loans	1. Amount Owed (amount of claim):

2. Creditor Name and Address:

3. Account Number, if any:

4. Date/range of dates when debt was incurred:

5. Contact person's name and address if different:

	1. Describe property:

2. Monthly payment amount:

3. Number of payments remaining:

	Who owes the debt?

 Self

 Spouse

 Joint

 Other:

Is there a codebtor or cosigner on this loan?

  No

  Yes
If yes, please provide name and address:

	  No

  Yes		
Other property loans	1. Amount Owed (amount of claim):

2. Creditor Name and Address:

3. Account Number, if any:

4. Date/range of dates when debt was incurred:

5. Contact person's name and address if different:

	1. Describe property:

2. Monthly payment amount:

3. Number of payments remaining:

	Who owes the debt?

 Self

 Spouse

 Joint

 Other:

Is there a codebtor or cosigner on this loan?

  No

  Yes
If yes, please provide name and address:

	  No

  Yes		

Other property loans	1. Amount Owed (amount of claim):

2. Creditor Name and Address:

3. Account Number, if any:

4. Date/range of dates when debt was incurred:

5. Contact person's name and address if different:

	1. Describe property:

2. Monthly payment amount:

3. Number of payments remaining:

	Who owes the debt?

 Self

 Spouse

 Joint

 Other:

Is there a codebtor or cosigner on this loan?

  No

  Yes
If yes, please provide name and address:

	  No

  Yes		
Other property loans	1. Amount Owed (amount of claim):

2. Creditor Name and Address:

3. Account Number, if any:

4. Date/range of dates when debt was incurred:

5. Contact person's name and address if different:

	1. Describe property:

2. Monthly payment amount:

3. Number of payments remaining:

	Who owes the debt?

 Self

 Spouse

 Joint

 Other:

Is there a codebtor or cosigner on this loan?

  No

  Yes
If yes, please provide name and address:

	  No

  Yes		

Other property loans	1. Amount Owed (amount of claim):

2. Creditor Name and Address:

3. Account Number, if any:

4. Date/range of dates when debt was incurred:

5. Contact person's name and address if different:

	1. Describe property:

2. Monthly payment amount:

3. Number of payments remaining:

	Who owes the debt?

 Self

 Spouse

 Joint

 Other:

Is there a codebtor or cosigner on this loan?

  No

  Yes
If yes, please provide name and address:

	  No

  Yes		
Other property loans	1. Amount Owed (amount of claim):

2. Creditor Name and Address:

3. Account Number, if any:

4. Date/range of dates when debt was incurred:

5. Contact person's name and address if different:

	1. Describe property:

2. Monthly payment amount:

3. Number of payments remaining:

	Who owes the debt?

 Self

 Spouse

 Joint

 Other:

Is there a codebtor or cosigner on this loan?

  No

  Yes
If yes, please provide name and address:

	  No

  Yes		

Part B. Credit Card Debts
Please list below all credit card debts that you owe OR that creditors claim you owe.

Type of Debt	Creditor Information:	Person(s) Responsible/Codebtor	Do you dispute the debt?	Office Use Only	
Major credit card debts (Visa, American Express, Master Card, Discover)	1. Amount Owed (amount of claim):

2. Creditor Name and Address:

3. Account Number, if any:

4. Date/range of dates when debt was incurred:

5. Contact person's name and address if different:

	Who incurred the debt?

 Self

 Spouse

 Joint

 Other:

Is there a codebtor or cosigner on this loan?

  No

  Yes
If yes, please provide name and address:

	  No

  Yes		
Major credit card debts (Visa, American Express, Master Card, Discover)	1. Amount Owed (amount of claim):

2. Creditor Name and Address:

3. Account Number, if any:

4. Date/range of dates when debt was incurred:

5. Contact person's name and address if different:

	Who incurred the debt?

 Self

 Spouse

 Joint

 Other:

Is there a codebtor or cosigner on this loan?

  No

  Yes
If yes, please provide name and address:

	  No

  Yes		

Major credit card debts (Visa, American Express, Master Card, Discover)	1. Amount Owed (amount of claim):

2. Creditor Name and Address:

3. Account Number, if any:

4. Date/range of dates when debt was incurred:

5. Contact person's name and address if different:

	Who incurred the debt?

 Self

 Spouse

 Joint

 Other:

Is there a codebtor or cosigner on this loan?

  No

  Yes
If yes, please provide name and address:

	  No

  Yes		
Major credit card debts (Visa, American Express, Master Card, Discover)	1. Amount Owed (amount of claim):

2. Creditor Name and Address:

3. Account Number, if any:

4. Date/range of dates when debt was incurred:

5. Contact person's name and address if different:

	Who incurred the debt?

 Self

 Spouse

 Joint

 Other:

Is there a codebtor or cosigner on this loan?

  No

  Yes
If yes, please provide name and address:

	  No

  Yes		

Major credit card debts (Visa, American Express, Master Card, Discover)	1. Amount Owed (amount of claim):

2. Creditor Name and Address:

3. Account Number, if any:

4. Date/range of dates when debt was incurred:

5. Contact person's name and address if different:

	Who incurred the debt?

 Self

 Spouse

 Joint

 Other:

Is there a codebtor or cosigner on this loan?

  No

  Yes
If yes, please provide name and address:

	  No

  Yes		
Major credit card debts (Visa, American Express, Master Card, Discover)	1. Amount Owed (amount of claim):

2. Creditor Name and Address:

3. Account Number, if any:

4. Date/range of dates when debt was incurred:

5. Contact person's name and address if different:

	Who incurred the debt?

 Self

 Spouse

 Joint

 Other:

Is there a codebtor or cosigner on this loan?

  No

  Yes
If yes, please provide name and address:

	  No

  Yes		

Department store credit card debts	1. Amount Owed (amount of claim):

2. Creditor Name and Address:

3. Account Number, if any:

4. Date/range of dates when debt was incurred:

5. Contact person's name and address if different:

	Who incurred the debt?

 Self

 Spouse

 Joint

 Other:

Is there a codebtor or cosigner on this loan?

  No

  Yes
If yes, please provide name and address:

	  No

  Yes		
Department store credit card debts	1. Amount Owed (amount of claim):

2. Creditor Name and Address:

3. Account Number, if any:

4. Date/range of dates when debt was incurred:

5. Contact person's name and address if different:

	Who incurred the debt?

 Self

 Spouse

 Joint

 Other:

Is there a codebtor or cosigner on this loan?

  No

  Yes
If yes, please provide name and address:

	  No

  Yes		

Other credit card debts (gas cards, phone cards, etc.)	1. Amount Owed (amount of claim):

2. Creditor Name and Address:

3. Account Number, if any:

4. Date/range of dates when debt was incurred:

5. Contact person's name and address if different:

	Who incurred the debt?

 Self

 Spouse

 Joint

 Other:

Is there a codebtor or cosigner on this loan?

  No

  Yes
If yes, please provide name and address:

	  No

  Yes		
Other credit card debts (gas cards, phone cards, etc.)	1. Amount Owed (amount of claim):

2. Creditor Name and Address:

3. Account Number, if any:

4. Date/range of dates when debt was incurred:

5. Contact person's name and address if different:

	Who incurred the debt?

 Self

 Spouse

 Joint

 Other:

Is there a codebtor or cosigner on this loan?

  No

  Yes
If yes, please provide name and address:

	  No

  Yes		

Other credit card debts (gas cards, phone cards, etc.)	1. Amount Owed (amount of claim):

2. Creditor Name and Address:

3. Account Number, if any:

4. Date/range of dates when debt was incurred:

5. Contact person's name and address if different:

	Who incurred the debt?

 Self

 Spouse

 Joint

 Other:

Is there a codebtor or cosigner on this loan?

  No

  Yes
If yes, please provide name and address:

	  No

  Yes		
Other credit card debts (gas cards, phone cards, etc.)	1. Amount Owed (amount of claim):

2. Creditor Name and Address:

3. Account Number, if any:

4. Date/range of dates when debt was incurred:

5. Contact person's name and address if different:

	Who incurred the debt?

 Self

 Spouse

 Joint

 Other:

Is there a codebtor or cosigner on this loan?

  No

  Yes
If yes, please provide name and address:

	  No

  Yes		

Cash advances	1. Amount Owed (amount of claim):

2. Creditor Name and Address:

3. Account Number, if any:

4. Date/range of dates when debt was incurred:

5. Contact person's name and address if different:

	Who incurred the debt?

 Self

 Spouse

 Joint

 Other:

Is there a codebtor or cosigner on this loan?

  No

  Yes
If yes, please provide name and address:

	  No

  Yes		
Cash advances	1. Amount Owed (amount of claim):

2. Creditor Name and Address:

3. Account Number, if any:

4. Date/range of dates when debt was incurred:

5. Contact person's name and address if different:

	Who incurred the debt?

 Self

 Spouse

 Joint

 Other:

Is there a codebtor or cosigner on this loan?

  No

  Yes
If yes, please provide name and address:

	  No

  Yes		

Part C. Medical Debts
Please list below all unpaid medical bill debts that you owe OR that creditors claim you owe.

Type of Debt	Creditor Information:	Person(s) Responsible/Codebtor	Do you dispute the debt?	Office Use Only	
Unpaid medical bills	1. Amount Owed (amount of claim):

2. Creditor Name and Address:

3. Account Number, if any:

4. Date/range of dates when debt was incurred:

5. Contact person's name and address if different:

6. Any additional information about the debt:

	Who incurred the debt?

 Self

 Spouse

 Joint

 Other:

Is there a codebtor or cosigner on this loan?

  No

  Yes
If yes, please provide name and address:

	  No

  Yes		
Unpaid medical bills	1. Amount Owed (amount of claim):

2. Creditor Name and Address:

3. Account Number, if any:

4. Date/range of dates when debt was incurred:

5. Contact person's name and address if different:

6. Any additional information about the debt:

	Who incurred the debt?

 Self

 Spouse

 Joint

 Other:

Is there a codebtor or cosigner on this loan?

  No

  Yes
If yes, please provide name and address:

	  No

  Yes		

Unpaid medical bills	1. Amount Owed (amount of claim):

2. Creditor Name and Address:

3. Account Number, if any:

4. Date/range of dates when debt was incurred:

5. Contact person's name and address if different:

6. Any additional information about the debt:

	Who incurred the debt?

 Self

 Spouse

 Joint

 Other:

Is there a codebtor or cosigner on this loan?

  No

  Yes
If yes, please provide name and address:

	  No

  Yes		
Unpaid medical bills	1. Amount Owed (amount of claim):

2. Creditor Name and Address:

3. Account Number, if any:

4. Date/range of dates when debt was incurred:

5. Contact person's name and address if different:

6. Any additional information about the debt:

	Who incurred the debt?

 Self

 Spouse

 Joint

 Other:

Is there a codebtor or cosigner on this loan?

  No

  Yes
If yes, please provide name and address:

	  No

  Yes		

Part D. Tax Debts
Please list below all unpaid tax debts that you owe OR that creditors claim you owe.

Type of Debt	Creditor Information:	Person(s) Responsible/ Codebtor	Do you dispute the debt?	Office Use Only	
Unpaid taxes	1. Amount Owed (amount of claim):

2. Creditor Name and Address:

3. Account Number, if any:

4. Date/range of dates when debt was incurred:

5. Contact person's name and address if different:

6. Any additional information about the debt:

	Who incurred the debt?

 Self

 Spouse

 Joint

 Other:

Is there a codebtor or cosigner on this loan?

  No

  Yes
If yes, please provide name and address:

	  No

  Yes		
Unpaid taxes	1. Amount Owed (amount of claim):

2. Creditor Name and Address:

3. Account Number, if any:

4. Date/range of dates when debt was incurred:

5. Contact person's name and address if different:

6. Any additional information about the debt:

	Who incurred the debt?

 Self

 Spouse

 Joint

 Other:

Is there a codebtor or cosigner on this loan?

  No

  Yes
If yes, please provide name and address:

	  No

  Yes		
Unpaid taxes	1. Amount Owed (amount of claim):

2. Creditor Name and Address:

3. Account Number, if any:

4. Date/range of dates when debt was incurred:

5. Contact person's name and address if different:

6. Any additional information about the debt:

	Who incurred the debt?

 Self

 Spouse

 Joint

 Other:

Is there a codebtor or cosigner on this loan?

  No

  Yes
If yes, please provide name and address:

	  No

  Yes		
Unpaid taxes	1. Amount Owed (amount of claim):

2. Creditor Name and Address:

3. Account Number, if any:

4. Date/range of dates when debt was incurred:

5. Contact person's name and address if different:

6. Any additional information about the debt:

	Who incurred the debt?

 Self

 Spouse

 Joint

 Other:

Is there a codebtor or cosigner on this loan?

  No

  Yes
If yes, please provide name and address:

	  No

  Yes		

Part E. Student Loan Debts
Please list below all Student Loan debts that you owe OR that creditors claim you owe.

Type of Debt	Creditor Information:	Person(s) Responsible/Codebtor	Do you dispute the debt?	Office Use Only	
Student loan	1. Amount Owed (amount of claim):

2. Creditor Name and Address:

3. Account Number, if any:

4. Date/range of dates when debt was incurred:

5. Contact person's name and address if different:

6. Any additional information about the debt:

	Who incurred the debt?

 Self

 Spouse

 Joint

 Other:

Is there a codebtor or cosigner on this loan?

  No

  Yes
If yes, please provide name and address:

	  No

  Yes		
Student loan	1. Amount Owed (amount of claim):

2. Creditor Name and Address:

3. Account Number, if any:

4. Date/range of dates when debt was incurred:

5. Contact person's name and address if different:

6. Any additional information about the debt:

	Who incurred the debt?

 Self

 Spouse

 Joint

 Other:

Is there a codebtor or cosigner on this loan?

  No

  Yes
If yes, please provide name and address:

	  No

  Yes		
Student loan	1. Amount Owed (amount of claim):

2. Creditor Name and Address:

3. Account Number, if any:

4. Date/range of dates when debt was incurred:

5. Contact person's name and address if different:

6. Any additional information about the debt:

	Who incurred the debt?

 Self

 Spouse

 Joint

 Other:

Is there a codebtor or cosigner on this loan?

  No

  Yes
If yes, please provide name and address:

	  No

  Yes		
Student loan	1. Amount Owed (amount of claim):

2. Creditor Name and Address:

3. Account Number, if any:

4. Date/range of dates when debt was incurred:

5. Contact person's name and address if different:

6. Any additional information about the debt:

	Who incurred the debt?

 Self

 Spouse

 Joint

 Other:

Is there a codebtor or cosigner on this loan?

  No

  Yes
If yes, please provide name and address:

	  No

  Yes		

Part F. Other Debts
Please list below all debts not listed above that you owe OR that creditors claim you owe.
Please Describe the Type of Debt
(e.g. unpaid rent, alimony or child support, service fees, other bank loans, or personal loans.)	Creditor Information:	Person(s) Responsible/Codebtor	Do you dispute the debt?	Office Use Only	
Describe:	1. Amount Owed (amount of claim):

2. Creditor Name and Address:

3. Account Number, if any:

4. Date/range of dates when debt was incurred:

5. Contact person's name and address if different:

6. Any additional information about the debt:
	Who incurred the debt?

 Self

 Spouse

 Joint

 Other:

Is there a codebtor or cosigner on this loan?

  No

  Yes
If yes, please provide name and address:

	  No

  Yes		
Describe:	1. Amount Owed (amount of claim):

2. Creditor Name and Address:

3. Account Number, if any:

4. Date/range of dates when debt was incurred:

5. Contact person's name and address if different:

6. Any additional information about the debt:

	Who incurred the debt?

 Self

 Spouse

 Joint

 Other:

Is there a codebtor or cosigner on this loan?

  No

  Yes
If yes, please provide name and address:

	  No

  Yes		
Describe:	1. Amount Owed (amount of claim):

2. Creditor Name and Address:

3. Account Number, if any:

4. Date/range of dates when debt was incurred:

5. Contact person's name and address if different:

6. Any additional information about the debt:

	Who incurred the debt?

 Self

 Spouse

 Joint

 Other:

Is there a codebtor or cosigner on this loan?

  No

  Yes
If yes, please provide name and address:

	  No

  Yes		
Describe:	1. Amount Owed (amount of claim):

2. Creditor Name and Address:

3. Account Number, if any:

4. Date/range of dates when debt was incurred:

5. Contact person's name and address if different:

6. Any additional information about the debt:

	Who incurred the debt?

 Self

 Spouse

 Joint

 Other:

Is there a codebtor or cosigner on this loan?

  No

  Yes
If yes, please provide name and address:

	  No

  Yes		

Describe:	1. Amount Owed (amount of claim):

2. Creditor Name and Address:

3. Account Number, if any:

4. Date/range of dates when debt was incurred:

5. Contact person's name and address if different:

6. Any additional information about the debt:

	Who incurred the debt?

 Self

 Spouse

 Joint

 Other:

Is there a codebtor or cosigner on this loan?

  No

  Yes
If yes, please provide name and address:

	  No

  Yes		
Describe:	1. Amount Owed (amount of claim):

2. Creditor Name and Address:

3. Account Number, if any:

4. Date/range of dates when debt was incurred:

5. Contact person's name and address if different:

6. Any additional information about the debt:

	Who incurred the debt?

 Self

 Spouse

 Joint

 Other:

Is there a codebtor or cosigner on this loan?

  No

  Yes
If yes, please provide name and address:

	  No

  Yes		

Section 4 - Unexpired Leases and Contracts (Schedule G)
List below any leases or contracts that are still current and to which you are a party.  Include residential, car and business leases, and service or business contracts.

Description of Lease or Contract	Name and Address of Other Party or Parties	Date  Contract Expires	Office Use Only	

	

	

	

	

	

	

	

	

	

	

	

	

	

	

Section 5 - Current Income (Schedule I)

Part A. Debtor's Employer Information
Name and Address of your employer:

                                                                
                                                                
How long have you been employed at this job:                                         
Occupation (please state job title or provide brief description):                                         

Second employer (if applicable):
Name and Address of your Second employer:

                                                                
                                                                
How long have you been employed at this second job:                                         
Occupation (please state job title or provide brief description):                                         
Notes:                                         

Part B. Joint Debtor's (Spouse's) Employer Information
Name and Address of your spouse's employer:

                                                                
                                                                
How long has spouse been employed at this job:                                         
Occupation (please state job title or provide brief description):                                         

Second employer (if applicable):
Name and Address of your spouse's Second employer:

                                                                
                                                                
How long has spouse been employed at this second job:                                         
Occupation (please state job title or provide brief description):                                         
Notes:                                         

Part C. Debtor's Wage Information
What is the gross amount of your paycheck, before taxes/other deductions are taken out?			
How often do you get paid?  once a week  every two weeks 
 twice a month  once a month  other                                         		
What is your estimated overtime pay per month?			
How much is taken out of each paycheck for taxes, Medicare, and social security? (combined total)			
How much is taken out of each paycheck for Mandatory Contributions to Retirement?		
How much is taken out of each paycheck for Voluntary Contributions to Retirement?		
How much is taken out of each paycheck for Required Repayments of Retirement fund Loans?		
How much is automatically deducted for insurance?			
How much is taken out for Domestic Support Obligations?		
How much is deducted for union dues?			
Other Deduction (describe):                                                                			
Other Deduction (describe):                                                                			
Other Deduction (describe):                                                                			
Do you receive income from business operations outside of your regular paycheck listed above?
 No  Yes
If yes, how much do you receive per month?			
Do you receive income from interest or dividends outside of your regular paycheck listed above?
 No  Yes
If yes, how much do you receive per month?			
Do you receive income from alimony or family support payments for your use or for the care of your dependents?
 No  Yes
If yes, how much do you receive per month?			
Do you receive income from Unemployment?
 No  Yes
If yes, how much do you receive per month?			
Do you receive income from Social Security?
 No  Yes
If yes, how much do you receive per month?			
Do you receive monetary government assistance?
 No  Yes
If yes, please describe:                                                                
How much do you receive per month?			
Do you receive retirement or pension money?
 No  Yes
If yes, how much do you receive per month?			
Do you have any other source of income not listed?
 No  Yes
If yes, please describe                                                                
How much do you receive per month?			
Are you expecting any increase or decrease in salary next year? 
 No  Yes
If yes, please describe                                                                	

Part D. Joint Debtor's (Spouse's) Wage Information
What is the gross amount of your paycheck, before taxes/other deductions are taken out?			
How often do you get paid?  once a week  every two weeks 
 twice a month  once a month  other                                         		
What is your estimated overtime pay per month?			
How much is taken out of each paycheck for taxes, Medicare, and social security? (combined total)			
How much is taken out of each paycheck for Mandatory Contributions to Retirement?		
How much is taken out of each paycheck for Voluntary Contributions to Retirement?		
How much is taken out of each paycheck for Required Repayments of Retirement fund Loans?		
How much is automatically deducted for insurance?			
How much is taken out for alimony or family support for the care of your dependents?		
How much is deducted for union dues?			
Other Deduction (describe):                                                                			
Other Deduction (describe):                                                                			
Other Deduction (describe):                                                                			
Do you receive income from business operations outside of your regular paycheck listed above?
 No  Yes
If yes, how much do you receive per month?			
Do you receive income from interest or dividends outside of your regular paycheck listed above?
 No  Yes
If yes, how much do you receive per month?			
Do you receive income from alimony or family support payments for your use or for the care of your dependents?
 No  Yes
If yes, how much do you receive per month?			
Do you receive income from Unemployment?
 No  Yes
If yes, how much do you receive per month?			
Do you receive income from Social Security?
 No  Yes
If yes, how much do you receive per month?			
Do you receive monetary government assistance?
 No  Yes
If yes, please describe:                                                                
How much do you receive per month?			
Do you receive retirement or pension money?
 No  Yes
If yes, how much do you receive per month?			
Do you have any other source of income not listed?
 No  Yes
If yes, please describe                                                                
How much do you receive per month?			
Are you expecting any increase or decrease in salary next year? 
 No  Yes
If yes, please describe                                                                	

Part E. Debtor's Current Monthly Income Calculation
Fill in your monthly income for the categories below in the column labeled "Month 1." If your income for one of the below categories varies from month to month, complete the below chart by entering in your income for all six months.
	Month 1
(last month)
        /        	Month 2
(2 months ago)
        /        	Month 3
        /        	Month 4
        /        	Month 5
        /        	Month 6
        /        	For Office Use Only	
Gross wages, salary, tips, bonuses, overtime, commissions.								
Income from operation of business:
    a. Gross Income
 -  b. Expenses
 = c. Net Income.								
Rent and other real property income::
    a. Gross Income
 -  b. Expenses
 = c. Net Income.								
Interest, dividends, and royalties.
								
Pension and retirement income (NOT Social Security).								
Regular contributions from others to the household expenses, including child support.								
Unemployment Compensation.
								
Social Security income.
								
Other sources not already mentioned. Describe:

								

Part F. Joint Debtor's (Spouse's) Current Monthly Income Calculation
Fill in your monthly income for the categories below in the column labeled "Month 1." If your income for one of the below categories varies from month to month, complete the below chart by entering in your income for all six months.
	Month 1
(last month)
        /        	Month 2
(2 months ago)
        /        	Month 3
        /        	Month 4
        /        	Month 5
        /        	Month 6
        /        	For Office Use Only	
Gross wages, salary, tips, bonuses, overtime, commissions.								
Income from operation of business:
    a. Gross Income
 -  b. Expenses
 = c. Net Income.								
Rent and other real property income::
    a. Gross Income
 -  b. Expenses
 = c. Net Income.								
Interest, dividends, and royalties.
								
Pension and retirement income (NOT Social Security).								
Regular contributions from others to the household expenses, including child support.								
Unemployment Compensation.
								
Social Security income.
								
Other sources not already mentioned. Describe:

								

Section 6 - Current Expenses (Schedule J)
1. Is this a Joint Filing with your Spouse?
 No  Yes

2. Please list all dependents of you and your spouse with their age and relationship to you (if applicable).
Relationship		Age		Who does the dependent live with?	

    		    		    	

Do you and your spouse live separately and maintain separate households?   No  Yes.  If yes, please let your attorney know and they will have to provide you with an additional copy of this section to detail the expenses for the completely separate household.

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.

3.  Do your expenses include another person's expenses other than yourself and your dependents?
 No  Yes

Indicate how much you pay for each item each month:
4.	Primary rent or home mortgage:	$		
	Does that amount include real estate taxes?  
 No  Yes
If no, how much do you pay? $                    		
	Does that amount include property, homeowner's, or renter's insurance? 
 No  Yes
If no, how much do you pay? $                    		
	Does that amount include any home maintenance, repair, or upkeep expenses?
 No  Yes
If no, how much do you pay? $                    		
	Does that amount include any homeowner's association or condominium dues?
 No  Yes
If no, how much do you pay? $                    		
5.	Are there additional mortgage payments?
 No  Yes
If yes, how much do you pay? $                    			
6.	Utilities:		
	a. Electricity and heating fuel:	$		
	b. Water and sewer:	$		
	c. Telephone service/long distance:	$		
	d. Do you have any other utility bills?  If yes, describe and enter monthly amount below:		
		$		
		$		
		$		
7.	Food and housekeeping supplies	$		
8.	Childcare  and Children Education Costs	$		
9.	Clothing, laundry, and dry cleaning:	$		
10.	Personal care products and services:	$		
11.	Medical and dental expenses:	$		
12.	Transportation (do NOT include car payments):	$		
13.	Recreation,entertainment, newspapers, magazines, and books:	$		
14.	Charitable contributions and religious donations:	$		
15.	Insurance NOT deducted from wages or included in home mortgage payments or other real estate property expenses: (Do not include amounts entered in Line 4 or Line 20)		
	a. Life insurance:	$		
	b. Health insurance:	$		
	c. Auto insurance:	$		
	d. Other insurance (describe and list monthly amount):		
		$		
		$		
		$		
16.	Tax bills NOT deducted from wages or included in home mortgage payments or other real estate property expenses:		
		$		
		$		
		$		

17.	Installment payments for car, furniture, etc. (Describe):		
		$		
		$		
		$		
		$		
		$		
		$		
18.	Alimony, maintenance and support paid to others:	$		
19.	Payments for support of additional dependents not living at your home:	$		
20.	Other Real Estate Property expenses NOT included with Rent or Home Mortgage Property   (Do not include amounts entered in Line 4 or Line 5)		
	a. Mortgage payment on other Real Estate Property	$		
	b. Taxes on other Real Estate Property	$		
	c. Other Real Property, Homeowner's, or Renter's Insurance payments	$		
	d. Home maintenance (including repairs and upkeep)	$		
	e. Homeowner's association or condominium dues	$		
21.	Other expenses (Describe): (please see "Additional Expenses" below before putting anything here)		
		$		
		$		
		$		
		$		
		$		
		$		
	Describe any increase or decrease in expenses you expect to occur within the next year?		

Due to the nature of the Federal Bankruptcy forms there is a special separate category of expenses that needs to be filled out with some unusual numbering.  Please ignore the numbering and fill out everything that you can below:

17.	Additional Expenses (707(b)Expenses for Form 122)
Mandatory payroll deductions not already listed:		
		$		
		$		
		$		
19.	Court ordered payments not already listed:		
		$		
		$		
		$		
20.	Education for employment or for a physically or mentally challenged child:	$		
21.	Child care (baby sitting, day care, nursery & preschool, etc.):	$		
25.	Disability Insurance (if not listed above):	$		
	Health Savings Account:	$		
26.	Care for elderly, chronically ill or disabled family members:	$		
27.	Protection from family violence:	$		
29.	Education expense for your children under 18:	$		
41. (c13s)	Non-mandatory contributions to retirement accounts (including loan repayments):		
		$		
		$		
		$		

Section 7 - Statement of Financial Affairs (Form 107)
If you are filing jointly with your spouse, include information about both you and your spouse.
1. List every address where you have lived other than where you live now during the last 3 years.
 NONE

Previous Address(es)		
From		
To	

2. If you lived with a spouse or domestic partner in a community property state or territory (Arizona, California, Idaho, Louisiana, Nevada, New Mexico, Puerto Rico, Texas, Washington, and Wisconsin) within the last 8 years, list the state or territory where you lived and the name and current address of your spouse or domestic partner.
 NONE

Community Property State or Territory		
Name and Address of Spouse or Domestic Partner	

3. List the total amount of income that you received from all jobs and all businesses, including part-time activities, during this year and the two previous calendar years.
 NONE

Debtor

Period		Source of income		Gross income (before deductions and exclusions)		
January 1 of this year through date of commencement of case		 Wages, commissions, bonuses, tips
Operating a business				
Last year (January 1 - December 31)		 Wages, commissions, bonuses, tips
Operating a business				
The year before last (January 1 - December 31)		 Wages, commissions, bonuses, tips
Operating a business				

Spouse (if applicable)

Period		Source of income		Gross income (before deductions and exclusions)		
January 1 of this year through date of commencement of case		 Wages, commissions, bonuses, tips
Operating a business				
Last year (January 1 - December 31)		 Wages, commissions, bonuses, tips
Operating a business				
The year before last (January 1 - December 31)		 Wages, commissions, bonuses, tips
Operating a business				

4. List any other income that you received during this year and the two previous calendar years (this includes government assistance, social security, retirement benefits, etc.). 
 NONE

Debtor

Period		Source of income (describe)		Gross income (before deductions and exclusions)		
January 1 of this year through date of commencement of case						
Last year (January 1 - December 31)						
The year before last (January 1 - December 31)						

Spouse (if applicable)

Period		Source of income		Gross income (before deductions and exclusions)		
January 1 of this year through date of commencement of case						
Last year (January 1 - December 31)						
The year before last (January 1 - December 31)						

5. If your debts are primarily consumer debts (i.e. non-business), list each creditor to whom you paid a total of $600 or more within the last 90 days. Do not include payments for domestic support obligations, such as child support and alimony. 
 NONE

Name and Address of Creditor		
Dates of Payment		
Total Amount Paid		
Amount Still Owed		Was this payment for ...	
								 Mortgage
 Car
 Credit card
 Loan repayment
 Suppliers or vendor
 Other:

Name and Address of Creditor		
Dates of Payment		
Total Amount Paid		
Amount Still Owed		Was this payment for ...	
								 Mortgage
 Car
 Credit card
 Loan repayment
 Suppliers or vendor
 Other:

Name and Address of Creditor		
Dates of Payment		
Total Amount Paid		
Amount Still Owed		Was this payment for ...	
								 Mortgage
 Car
 Credit card
 Loan repayment
 Suppliers or vendor
 Other:
	
6. If your debts are primarily non-consumer debts (i.e. business), list each creditor to whom you paid a total of $6,425 or more in one or more payments within the last 90 days. Do not include payments for domestic support obligations, such as child support and alimony.
 NONE

Name and Address of Creditor		
Dates of Payment		
Total Amount Paid		
Amount Still Owed		Was this payment for ...	
								 Mortgage
 Car
 Credit card
 Loan repayment
 Suppliers or vendor
 Other:

Name and Address of Creditor		
Dates of Payment		
Total Amount Paid		
Amount Still Owed		Was this payment for ...	
								 Mortgage
 Car
 Credit card
 Loan repayment
 Suppliers or vendor
 Other:

Name and Address of Creditor		
Dates of Payment		
Total Amount Paid		
Amount Still Owed		Was this payment for ...	
								 Mortgage
 Car
 Credit card
 Loan repayment
 Suppliers or vendor
 Other:

7. List all payments that you made within the past 1 year to any "insider." ("Insiders" include your relatives, your business partners and their relatives, your corporations, or your affiliates.)
 NONE

Name and Address of Insider		
Dates of Payment		
Total Amount Paid		
Amount Still Owed		
Reason for payment	

8. List all payments or transfers of property that you made within the past 1 year that benefitted an "insider." 
 NONE

Name and Address of Insider		
Dates of Payment		
Total Amount Paid		
Amount Still Owed		
Reason for payment (include the creditor's name)	

9. List any lawsuits, court actions, or administrative proceedings to which you are or were a party within the past 1 year.
 NONE

Case Title and Case Number		
Nature of the Case		
Court or Agency and Location		
Status or Disposition	

10. Describe all property that has been repossessed, foreclosed, garnished, attached, seized, or levied within the past 1 year.
 NONE

Creditor's Name and Address
		
Description and Value of Property		
Date		
Explain what happened
	
						 Property was repossessed
 Property was foreclosed
 Property was garnished
 Property was attached, seized, or levied	

Creditor's Name and Address
		
Description and Value of Property		
Date		
Explain what happened
	
						 Property was repossessed
 Property was foreclosed
 Property was garnished
 Property was attached, seized, or levied	

11.List all setoffs made by any creditor, including a bank or financial institution, against a debt or deposit within 90 days before the filing of this case. Include any refusals by a creditor to make a payment because you owed a debt.
 NONE

Creditor's Name and Address		
Description of action taken by creditor		
Date Action Taken		
Setoff Amount and Last 4 Digits of Account Number

12. Within the past 1 year, was any of your property in the possession of an assignee for the benefit of creditors, a court-appointed receiver, a custodian, or another official?

 No

 Yes

13. List any gifts that you made within the past 2 years that have a total value of more than $600 per person.
 NONE

Name and Address of Recipient		
Relationship to You		
Description of Gifts		
Dates Gifts Given
		
Value	

14. List any gifts or contributions that you made to a charity within the past 2 years that have a total value of more than $600.
 NONE

Name and Address of Charity		
Description of Contribution
		
Contribution Date
		
Value	

15. List all losses from fire, theft, or other disaster, or gambling within the past 1 year or since the filing of this case.
 NONE

Description of Property and How Loss Occurred
		
Description of any Insurance Coverage (include the amount that insurance has paid)		
Date of Loss		
Value of Property Lost	

16. List all payments made or property transferred by you or by someone acting on your behalf to anyone you consulted about filing for bankruptcy or preparing a bankruptcy petition within the past 1 year. Include any attorneys, bankruptcy petition preparers, or credit counseling agencies.
 NONE

Name and Address of Person Paid		
Name of Person Who Made the Payment, if Not You		
Description and Value of Any Property Transferred		
Date of Payment or Transfer		
Amount of Payment	

17. List all payments made or property transferred by you or by someone acting on your behalf within the past 1 year to anyone who promised to help you deal with your creditors or to make payments to your creditors.
 NONE

Name and Address of Person Paid		
Name of Person Who Made the Payment, if Not You		
Description and Value of Any Property Transferred		
Date of Payment or Transfer		
Amount of Payment	

18. List all property, other than property transferred in the ordinary course of your business or financial affairs, that you sold, traded, or transferred either absolutely or as a security within the past 2 years.
 NONE

Name and Address of Person Who Received the Transfer/ Relationship to You		
Description and Value of Property Transferred		Describe Any Property or Payments Received or Debts Paid in Exchange		
Date of Transfer	

19. List all property you transferred within the past 10 years to a self-settled trust or a similar device of which you are a beneficiary.
 NONE

Name of Trust		
Description and Value of Property Transferred		
Date of Transfer	

20. List all financial accounts and instruments held in your name or for your benefit that were closed, sold, moved, or transferred within the past 1 year.
 NONE

Name and Address of Institution		
Last 4 Digits of Account Number		
Type of Account or Instrument		
Date Account Was Closed, Sold, Moved, or Transferred		
Last Balance Before Closing or Transfer	
				 Checking
 Savings
 Money Market
 Brokerage
 Other:

Name and Address of Institution		
Last 4 Digits of Account Number		
Type of Account or Instrument		
Date Account Was Closed, Sold, Moved, or Transferred		
Last Balance Before Closing or Transfer	
				 Checking
 Savings
 Money Market
 Brokerage
 Other:

21. List each safe deposit box or other depository for securities, cash, or other valuables that you have had within the past 1 year.
 NONE

Name and Address of Financial Institution		
Name and Address of Anyone With Access to Box or Depository		
Description of Contents		
Do You Still Have It?	
						 No
 Yes	

22. List any storage unit or place other than your home in which you have stored property within the past 1 year.
 NONE

Name and Address of Storage Facility		
Name and Address of Anyone With Access to Box or Depository		
Description of Contents		
Do You Still Have It?	
						 No
 Yes	

23. List all property that you hold or control that is owned by someone else.
 NONE

Name and Address of Owner		
Location of Property		
Description of Property		
Value	

24. List every site for which you received notice by a governmental unit that you may be liable under or in violation of an environmental law. Include the name and address of the governmental unit, the date of the notice, and, if known, the environmental law.
Environmental law means any federal, state, or local statue or regulation regulating pollution, contamination, releases of hazardous or toxic substances, wastes or material into the air, land, soil surface water, ground water, or other medium, including, statutes or regulations controlling the cleanup of these substances, wastes, or material.
Site means any location, facility, or property as defined under any environmental law, whether you own, operate, or utilize it or used to own, operate, or utilize it, including disposal sites.
Hazardous material means anything an environmental law defines as a hazardous waste, hazardous substance, toxic substance, hazardous material, pollutant, or contaminant or similar term.

 NONE

Site Name and Address		
Name and Address of Governmental Unit		
Environmental Law, If You Know It		
Date of Notice	

25. List the name and address of every site for which you have notified a governmental unit of a hazardous material release. Include the name and address of the governmental unit to which the notice was sent, the date of the notice, and, if know, the environment law.
 NONE

Site Name and Address		
Name and Address of Governmental Unit		
Date of Notice		
Environmental Law	

26. List all judicial or administrative proceedings, including settlements and orders, under any environmental law to which you have been a party. Include the case title and the case number, the court or agency, the nature of the case, and the status.
 NONE

Case Title and Case Number		
Name and Address of Court or Agency		
Nature of the Case		
Status of the Case	
						 Pending
 On Appeal
 Concluded	

27. List the name and address, nature of business, name of accountant or bookkeeper, Employer Identification Number (EIN), and dates of operation of every business you owned or with which you had any of the following connections within the past 4 years.

 A sole proprietor or self-employed in a trade, profession, or other activity, either full-time or part-time
 A member of a limited liability company (LLC) or limited liability partnership (LLP)
 A partner in a partnership
 An officer, director, or managing executive of a corporation
 An owner of at least 5% of the voting or equity securities of a corporation

 NONE

Business Name and Address		
Nature of Business		
Name of Accountant or Bookkeeper 		
Employer Identification Number (EIIN)		
Beginning and End Dates of Operation	

28. List all financial institutions, creditors, or other parties to which you gave a financial statement about your business within the past 2 years.
 NONE

Name and Address		
Date Issued	

DISCLOSURE CERTIFICATE

I, the undersigned, hereby attest and affirm that all debts, whether joint debts, co-signed debts, claims or lawsuits for collection of debts, whether disputed or not, have been listed on my questionnaire.  I also attest and affirm that all information about my assets and property listed on my questionnaire is complete and accurate.
I acknowledge that my attorney relies on the information provided in this questionnaire in order to assist and advise me, and that it is my responsibility to provide my attorney with a full, complete and accurate financial disclosure.  I further agree to update my attorney with regard to any incomplete information contained herein.
I further acknowledge that in the event a creditor is omitted from any bankruptcy petition filed by my attorney as a result of an omission on this questionnaire, I will not have the protection of the Bankruptcy Court from actions by that creditor.
Date_________________          Signature____________________________________

Date_________________          Signature____________________________________