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enses ....................................................................... $_____________ Bankruptcy Questionnaire 16 ......................................................... $_____________ You Spouse Total Monthly Income .............................................. $_____________ $_____________ Total Monthly ExpInsert totals from previous pages) Total Assets ...........................................................................................$_____________ Total Debts ..................................icipate any change of more than 10% in any of the above categories within the next year? Explain: ___________________________________________________ Bankruptcy Questionnaire 15 Financial Summary (.................................................................. $_____________ Total Monthly Expenses ..................................................................... $_____________ Do you ant.................... $_____________ Other: .................................................................................................... $_____________ Other: ............................................. $_____________ Regular expenses from operation of business, profession, or farm: .... $_____________ Other: ................................................................................................. $_____________ Alimony, maintenance, and support paid to others: .............................. $_____________ Support of dependents not living at your home: .................................. $_____________ Other........................................................................................... $_____________ Subtotal of Installment Payments ............................. Auto............................................................................................. $_____________ Other.................................................................................al of Insurance ................................................................. $_____________ Taxes (not deducted from wages or included in mortgage payments):. $_____________ Installment payments:.................................................................. $_____________ Other........................................................................................... $_____________ Subtot.......................................... $_____________ Health.......................................................................................... $_____________ Auto..........................om wages or included in mortgage payments): Homeowner's or renter's............................................................. $_____________ Life....................................................ntertainment, newspapers, magazines, etc.: .. $_____________ Charitable contributions:........................................................................ $_____________ Insurance (not deducted fr............................................................. $_____________ Transportation (not including car payments):........................................ $_____________ Recreation, clubs and e............................................ $_____________ Laundry and dry cleaning:..................................................................... $_____________ Medical and dental expenses:..$_____________ Food:...................................................................................................... $_____________ Clothing:....................................................._________ Subtotal of Utilities ..................................................................... $_____________ Home maintenance (repairs and upkeep):............................................ .................................................................................. $_____________ Other .......................................................................................... $____nd heating fuel ......................................................... $_____________ Water and sewer ..................................................................... $_____________ Telephone ............................................. $_____________ Property insurance ................................................................................ $_____________ Utilities: Electricity aankruptcy Questionnaire 14 What Are Your Monthly Expenses? Rent or home mortgage payment (include lot rent for mobile home):... $_____________ Real estate taxes .....................................____________ Total Monthly Non-Wage Income ............................ $_____________ $_____________ Total Monthly Income ............................................ $_____________ $_____________ B_______________________________________________ Summary of Monthly Income (Insert totals from previous pages) You Spouse Total Net Monthly Wage Income ............................. $_____________ $_otal Monthly Non-Wage Income ............................ $_____________ $_____________ Do you anticipate any change of more than 10% in any of the above categories within the next year? Explain: ____________ Pension or retirement income: ................................ $_____________ $_____________ Other monthly income: ............................................ $_____________ $_____________ T..... $_____________ $_____________ Alimony or child support payments: ........................ $_____________ $_____________ Social Security or other government assistance: .... $_____________ $_____.......... $_____________ $_____________ Income from real property: ...................................... $_____________ $_____________ Interest and dividends: .......................................n 10% in any of the above categories within the next year? Explain: ___________________________________________________ Monthly Non-Wage Income You Spouse Income from business, profession, or farm: .. $_____________ $_____________ Total Net Monthly Wage Income (take-home pay: total monthly wages minus payroll deductions) ...... $_____________ $_____________ Do you anticipate any change of more tha_______ ) ............... $_____________ $_____________ Other (Specify: _________________ ) ................. $_____________ $_____________ Subtotal Of Payroll Deductions ....................................................................... $_____________ $_____________ Union dues ............................................................ $_____________ $____________ Other (Specify: __________...................................... $_____________ $_____________ Social Security ...................................................... $_____________ $_____________ Insurance ................................ $_____________ $_____________ Total Monthly Wages ............................................. $_____________ $_____________ Less payroll deductions: Taxes .............................. Income You Spouse Gross wages, salary, and commissions (pro-rate if not paid monthly): ................................ $_____________ $_____________ Estimated monthly overtime: .....................__________ Name of employer ______________________________________________________ Address of employer _____________________________________________________ Bankruptcy Questionnaire 13 Monthly Wage.......................................................... $_____________ What Is Your Monthly Income? Occupation ____________________________________________________________ How long employed? _____.............................. $_____________ Miscellaneous Debts Total .................................................................... $_____________ Total Debts ................................... $_____________ Taxes Due Total ................................................................................... $_____________ Credit Card Debts Total ..........................................___ Accounts Payable You Owe Total ........................................................ $_____________ Rent You Owe Total ..........................................................................we Total .................................................................... $_____________ Loans You Owe Total ........................................................................... $__________..... $_____________ Total Miscellaneous Debts .................................................................... $_____________ Summary of Debts (Insert totals from previous pages) Mortgages You O (if any)? _________________ Term ______________________________________ Interest rate ________________ Amount due .....................................................................................riginated ________________________ Date incurred ________________ Do you dispute debt? _________________ Did you sign contract? ________________ Any legal action on this debt? ______ Name of co-signer______________________________________ Address _______________________________________________________________ Collateral _______________________________ Reason for debt _________________ Place debt o___________________ Interest rate ________________ Amount due.......................................................................................... $ _____________ To whom due ________________________________ Do you dispute debt? _________________ Did you sign contract? ________________ Any legal action on this debt? ______ Name of co-signer (if any)? _________________ Term ____________________________________________________________________________ Collateral _______________________________ Reason for debt _________________ Place debt originated ________________________ Date incurred ____................................................ $_____________ Bankruptcy Questionnaire 12 Miscellaneous Debts To whom due __________________________________________________________ Address ______ou sign contract? ________________ Amount due........................................................................................... $_____________ Total Credit Card Debts ........................____ Reason for debt ________________________________________________________ Place debt originated ________________________ Date incurred ________________ Do you dispute debt? _________________ Did y....................................... $_____________ Credit card company __________________ Credit card account # ________________ Address ___________________________________________________________ed ________________________ Date incurred ________________ Do you dispute debt? _________________ Did you sign contract? ________________ Amount due....................................................dit card account # ________________ Address _______________________________________________________________ Reason for debt ________________________________________________________ Place debt originat Did you sign contract? ________________ Amount due........................................................................................... $_____________ Credit card company __________________ Cre__________ Reason for debt ________________________________________________________ Place debt originated ________________________ Date incurred ________________ Do you dispute debt? _________________...........................$_____________ Credit Card Debts Credit card company __________________ Credit card account # ________________ Address ______________________________________________________________ ) .......... $_____________ Other (name of tax authority _____________________ ) .................... $_____________ Total Taxes Due ......................................................... (name of tax authority _____________________ ) ........ $_____________ Personal property (name of tax authority _____________________ ). $_____________ Real estate (name of tax authority ____________e ............................................................................. $ ____________ Taxes Due Federal income (name of tax authority _____________________ ) .... $_____________ State incoment past due? _____________________________ Late charge_________________ Total amount now due........................................................................... $_____________ Total Rent You Ow_______ Address of rental property ____________________ Date incurred ________________ Do you dispute debt? ___________________ Did you sign lease? ________________ Bankruptcy Questionnaire 11 Is re............................................... $_____________ Payable to _____________________________________________________________ Address ________________________________________________________you dispute debt? ___________________ Did you sign lease? ________________ Is rent past due? _____________________________ Late charge ________________ Total amount now due............................____________________________________________ Address _______________________________________________________________ Address of rental property ____________________ Date incurred _________________ Do ....................................... $_____________ Total Accounts Payable You Owe..........................................................$_____________ Rent You Owe Payable to _________________ debt? _________________ Did you sign contract? ________________ Is account past due? _________________________ Interest rate _________________ Total amount now due....................................__________________________________ Reason for debt ________________________________________________________ Place debt originated ________________________ Date incurred ________________ Do you dispute........................................................................ $_____________ Payable to ____________________________________ Account # ________________ Address _____________________________d ________________ Do you dispute debt? _________________ Did you sign contract? ________________ Is account past due? _________________________ Interest rate _________________ Total amount now due...ess _______________________________________________________________ Reason for debt ________________________________________________________ Place debt originated ________________________ Date incurre_________ Total amount now due........................................................................... $_____________ Payable to ____________________________________ Account # ________________ Addr____________________ Date incurred ________________ Do you dispute debt? _________________ Did you sign contract? ________________ Is account past due? _________________________ Interest rate _________ Account # ________________ Address _______________________________________________________________ Reason for debt ________________________________________________________ Place debt originated ____u Owe ........................................................................... $____________ Accounts Payable You Owe (Medical, Dental, Stores, etc.) Payable to ___________________________________gth of term _____________________________ Interest rate __________________ Total amount now due........................................................................... $_____________ Total Loans Yo__ Do you dispute debt? _____________ Did you sign loan contract? ________________ Bankruptcy Questionnaire 10 Any legal action on this debt? ______ Name of co-signer (if any)? _________________ Len_______________________________________________ Collateral _______________________________ Reason for debt _________________ Place debt originated ________________________ Date incurred ______________unt now due........................................................................... $_____________ Payable to ______________________________________ Loan # ________________ Address ________________n contract? ________________ Any legal action on this debt? ______ Name of co-signer (if any)? _________________ Length of term _____________________________ Interest rate __________________ Total amoeral _______________________________ Reason for debt _________________ Place debt originated ________________________ Date incurred ________________ Do you dispute debt? _____________ Did you sign loa Owe (Finance Company, Bank, Auto, or Personal) Payable to ______________________________________ Loan # ________________ Address _______________________________________________________________ Collat.................................................................. $_____________ Total Mortgages You Owe .................................................................... $_____________ Loans You________ Any legal action on this debt? ______ Name of co-signer (if any)? _________________ Length of term _____________________________ Interest rate __________________ Total amount now due.........on regarding this debt? ___________________________ Place debt originated ________________________ Date incurred ________________ Do you dispute debt? _________________ Did you sign contract? ______________________________ Property location ________________________________________________________ Reason for debt ________________________________________________________ Has there been any legal acti............................................................ $_____________ Payable to ___________________________________ Mortgage # ________________ Address ___________________________________________ Any legal action on this debt? ______ Name of co-signer (if any)? _________________ Length of term _____________________________ Interest rate __________________ Total amount now due..............._____________________________________________ Place debt originated ________________________ Date incurred ________________ Do you dispute debt? _________________ Did you sign contract? ______________rtgage # ________________ Address _______________________________________________________________ Property location ________________________________________________________ Reason for debt ___________................................................. $____________ Bankruptcy Questionnaire 9 What Are Your Debts? Mortgages You Owe (Home or Business) Payable to ___________________________________ Mo........................... $_____________ Miscellaneous Property Interests Total ................................................. $_____________ Total Assets ........................................al ............ $_____________ Other Debts Owed to You Total ............................................................ $_____________ Tax Refunds Due to You Total .................................................... $_____________ Accounts Receivable Total ................................................................... $_____________ Alimony, Support, or Property Settlements Owed to You Tot..... $_____________ Business Interests Total ....................................................................... $_____________ Bonds and Mutual Bond Funds Total ..................................... $_____________ Ira, Keogh, and/or Pension/Profit-Sharing Plans Total ......................... $_____________ Stocks and Mutual Funds Total ................................................................. $_____________ Miscellaneous Household and Personal Property Total ....................... $_____________ Insurance and Annuity Contracts Total ............................................._______ Cash and Bank Accounts Total............................................................. $_____________ Security Deposits Total .................................................................................... $_____________ Summary of Assets (Insert totals from previous pages) Real Estate Total .................................................................................. $__________________________________________________________________ Location ______________________________________________________________ Total Miscellaneous Property Interests ............................__________ Location ______________________________________________________________ Any other personal property not listed .................................................. $_____________ Description ________________________________ Any other personal property not listed .................................................. $_____________ Description __________________________________________________l property not listed .................................................. $_____________ Description ____________________________________________________________ Location ______________________________...................... $_____________ Description ____________________________________________________________ Location ______________________________________________________________ Any other persona____________________________________________________________ Location ______________________________________________________________ Any other personal property not listed ............................ocation ______________________________________________________________ Season tickets ...................................................................................... $_____________ Description 8 Tools ..................................................................................................... $_____________ Description ____________________________________________________________ L............ $_____________ Description ____________________________________________________________ Location ______________________________________________________________ Bankruptcy Questionnaire _____________________________________________ Location ______________________________________________________________ Farm supplies and seed ..........................................................._________________________________________________________ Farm equipment .................................................................................... $_____________ Description ___________________ Crops (growing or harvested) ............................................................... $_____________ Description ____________________________________________________________ Location _____............................................ $_____________ Description ____________________________________________________________ Location __________________________________________________________ption ____________________________________________________________ Location ______________________________________________________________ Animals .....................................................______ Location ______________________________________________________________ Business inventory ................................................................................ $_____________ Descri______________________________ Machinery, business equipment, etc. ....................................................$_____________ Description ______________________________________________________t, supplies, and furnishings ......................................... $_____________ Description ____________________________________________________________ Location ________________________________........................ $_____________ Description ____________________________________________________________ Location ______________________________________________________________ Office equipmen________________________________________________________ Location ______________________________________________________________ Airplane and accessories ..............................................Location ______________________________________________________________ Boat, marine motor, etc. ....................................................................... $_____________ Description ___________________ Auto, truck, or other vehicles ................................................................ $_____________ Description ____________________________________________________________ ........................................................$_____________ Description ____________________________________________________________ Location _______________________________________________________________________________________________________ Location ______________________________________________________________ Bankruptcy Questionnaire 7 Licenses, franchises, etc ...............___ Location ______________________________________________________________ Royalties, patents, copyrights, etc. ........................................................$_____________ Description _______________________________ Other contingent or unliquidated claims ............................................... $_____________ Description _________________________________________________________her person's life insurance policy .................................$_____________ Description ____________________________________________________________ Location ___________________________________...................... $_____________ Description ____________________________________________________________ Location ______________________________________________________________ Interests in anot___________________________________________________________ Location ______________________________________________________________ Interests in estates of decedents, etc. .........................................................$_____________ Miscellaneous Property Interests Future interest and/or life estates ......................................................... $_____________ Description _uthority ____________________________________________________ Address of tax authority __________________________________________________ Total Tax Refunds Due to You ................................. tax authority __________________________________________________ Other tax ............................................................................................... $_____________ Name of tax a State income tax ................................................................................... $_____________ Name of state __________________________________________________________ Address of Due to You Federal income tax ............................................................................... $_____________ Address of IRS office ______________________________________________________________ Address_______________________________________________________________ Total Other Debts Owed to You ............................................................ $_____________ Tax RefundsBankruptcy Questionnaire 6 Other debt owed to you ........................................................................ $_____________ Due from____________________________________________________.......................................... $_____________ Due from______________________________________________________________ Address_______________________________________________________________ _________________________________ Total Alimony, Support, or Property Settlements Owed to You .............$_____________ Other Debts Owed to You Other debt owed to you ........................................................................................................ $_____________ Due from ______________________________________________________________ Address ______________________________............... $_____________ Due from ______________________________________________________________ Address _______________________________________________________________ Property settlement ............................................ $_____________ Alimony, Support, or Property Settlements Owed to You Alimony .................................................................................._ Due from ______________________________________________________________ Address _______________________________________________________________ Total Accounts Receivable ............................_________________ Address _______________________________________________________________ Accounts owed to you ........................................................................... $_________________________ Accounts Receivable Accounts owed to you ............................................................................$_____________ Due from_____________________________________________................................................................................................. $_____________ Total Bonds and Mutual Bond Funds ................................................... $________________________________________ CUSIP or Certificate # ___________________________________________________ Number and type of shares _______________________________________________ Value ...._______________________________________________ Value ..................................................................................................... $_____________ Company _____________________ Bonds and Mutual Bond Funds Company _____________________________________________________________ CUSIP or Certificate # ___________________________________________________ Number and type of shares .......................................... $_____________ Bankruptcy Questionnaire 5 Total Business Interests ........................................................................ $____________ pe of business ________________________________________________________ Gross value $ _______________ Percentage share held _______________ Your net value .............................................................. $_____________ Joint Venture Interest Name ________________________________________________________________ Location ______________________________________________________________ Ty_____________________________________________ Gross value $ _______________ Percentage shares held _______________ Your net value ......................................................................________ Corporation Interest Name ________________________________________________________________ Location ______________________________________________________________ Type of business _________________________________ Gross value $ _______________ Percentage share held _______________ Your net value ....................................................................................... $_____ership Name ________________________________________________________________ Location ______________________________________________________________ Type of business __________________________________usiness ________________________________________________________ Your net value ....................................................................................... $_____________ Interest in Partn________ Business Interests Sole Proprietorship Name ________________________________________________________________ Location ______________________________________________________________ Type of b....................................................................................... $_____________ Total Stocks and Mutual Funds .............................................................$___________________________________ CUSIP or Certificate # ___________________________________________________ Number and type of shares _______________________________________________ Value .............._____________________________________ Value ..................................................................................................... $_____________ Company _______________________________s and Mutual Funds Company _____________________________________________________________ CUSIP or Certificate # ___________________________________________________ Number and type of shares __________..........................................................$_____________ Total IRA, Keogh, and/or Pension/Profit-Sharing Plans ........................$_____________ Bankruptcy Questionnaire 4 Stock______ Address _______________________________________________________________ Plan type ______________________________________________________________ Net value ......................................___________ Net value ................................................................................................$_____________ Company or administrator __________________________________________ or administrator_________________________________________________ Address _______________________________________________________________ Plan type ___________________________________________________...........................$_____________ Total Insurance and Annuity Contracts .................................................$_____________ IRA, Keogh, and/or Pension/Profit-Sharing Plans Company__________________________________________________________ Address_______________________________________________________________ Cash surrender value ..................................................$_____________ Annuity contract (face value) .........................................Policy Amount $_____________ Policy # _______________________________________________________________ Company____________________________________ Address_______________________________________________________________ Cash surrender value............................................................................ce (face value) .............................................Policy Amount $_____________ Policy # _______________________________________________________________ Company _____________________________ ______________________________________________________________ Total Miscellaneous Household and Personal Property ........................$_____________ Insurance and Annuity Contracts Life insuran_____________________________ Any other miscellaneous household and personal property ..................$_____________ Description ____________________________________________________________ Locationuipment ..............................................................$_____________ Description ____________________________________________________________ Location _________________________________.....................$_____________ Description ____________________________________________________________ Location ______________________________________________________________ Camera and hobby eq_____________________________ Location ______________________________________________________________ Bankruptcy Questionnaire 3 Firearms and sporting equipment ....................................._______________________________________ Jewelry and furs .................................................................................... $_____________ Description _______________________________............................................................................... $_____________ Description ____________________________________________________________ Location _______________________............ $_____________ Description ____________________________________________________________ Location ______________________________________________________________ Clothing .................._______________________________________________ Location _____________________________________________________________ Stamp, coin, or other collections ............................................... ______________________________________________________________ Books, pictures, or artwork.....................................................................$_____________ Description ____________________ Computer equipment..............................................................................$_____________ Description ____________________________________________________________ Location............................................... $_____________ Description ____________________________________________________________ Location ______________________________________________________________ Description ____________________________________________________________ Location ______________________________________________________________ Audio or video equipment ....................................................... $_____________ Miscellaneous Household and Personal Property Household furnishings .......................................................................... $______deposit ______________________________________________________ Name(s) on account _____________________________________________________ Total Security Deposits ..................................................................... $_____________ Held by _______________________________________________________________ Address _______________________________________________________________ Reason for ______________________________________________________ Name(s) on account _____________________________________________________ Security deposit ............................................................................ $_____________ Held by _______________________________________________________________ Address _______________________________________________________________ Reason for deposit ................... $_____________ Bankruptcy Questionnaire 2 Security Deposits (Held by Utilities, Landlords, etc.) Security deposit ...............................................................________________________________________________________ Name(s) on account _____________________________________________________ Total Cash and Bank Accounts ................................................................... $_____________ Bank _________________________________________________________________ Address _______________________________________________________________ Account # ________________________________________________________ Name(s) on account _____________________________________________________ Other account ............................................................................... $_____________ Held by _______________________________________________________________ Address _______________________________________________________________ Expiration date __________________________________________________ Name(s) on account _____________________________________________________ Certificate of deposit ......................................................................... $_____________ Bank _________________________________________________________________ Address _______________________________________________________________ Account # __________________________________________________________ Name(s) on account _____________________________________________________ Savings account ................................................................................ $_____________ Bank _________________________________________________________________ Address _______________________________________________________________ Account # ____________________................................................................................................. $_____________ Checking account ....................................................................................... $_____________ Total Real Estate .................................................................................. $_____________ Personal Property Cash and Bank Accounts Cash ....___/______ % Value of your share ............................................................................... $_____________ Amount of mortgage or other debt .......................................___________ Location ______________________________________________________________ Market Value: $ _______________ How held and percent held? (Joint tenants, tenancy-in-common, etc?) ________________ortgage or other debt ........................................................ $_____________ Bankruptcy Questionnaire 1 Other Property Description _________________________________________________ld? (Joint tenants, tenancy-in-common, etc?) ___________________/______ % Value of your share ............................................................................... $_____________ Amount of mDescription ____________________________________________________________ Location_______________________________________________________________ Market Value: $ _______________ How held and percent he................................................................ $_____________ Amount of mortgage or other debt ........................................................ $_____________ Other Property ___________________________________ Market Value: $ _______________ How held and percent held? (Joint tenants, tenancy-in-common, etc?) ___________________/______ % Value of your share ...............r debt .........................................................$_____________ Vacant Land Description ____________________________________________________________ Location ___________________________nts, tenancy-in-common, etc?) ___________________/______ % Value of your share ................................................................................$_____________ Amount of mortgage or othe_________________________________________________________ Location ______________________________________________________________ Market Value: $ _______________ How held and percent held? (Joint tena.................................................. $_____________ Amount of mortgage or other debt ........................................................ $_____________ Vacation Home Description ________________________ Market Value: $ _______________ How held and percent held? (Joint tenants, tenancy-in-common, etc?) ___________________/______ % Value of your share .............................kruptcy Questionnaire What Are Your Assets? Real Estate Personal Residence Description ____________________________________________________________ Location ___________________________________________her in contract, strict liability, or tort (including negligence or otherwise) arising in any way out of the use of these materials. An attorney should be consulted for all serious legal matters. Banential damages (including, but not limited to, procurement of substitute goods or services; loss of use, data, or profits; or business interruption) however caused and on any theory of liability, whetForms, Inc, its agents, partners, or affiliates, or ii) the providers, authors or publishers of the forms, be responsible or liable for any direct, indirect, incidental, special, exemplary, or consequxpress or implied warranties of merchantability, suitability or completeness for any of the materials for your particular needs. The materials are used at your own risk. In no event will: i) FindLegalt provide legal advice. The purchase and use of these materials is subject to the "Disclaimers and Terms of Use" found at findlegalforms.com. These materials are provided "AS-IS." We do not give any e complete this questionnaire. If you are filing jointly, include totals for both spouses. Disclaimer No Attorney-Client relationship is created by use of these materials. FindLegalForms, Inc. does noarding your finances. It will be necessary to consult your bills, payment records, paycheck stubs, mortgages, loan applications, checkbooks, tax returns and all other financial information in order to your property or trick creditors in any manner may result in the denial of your bankruptcy by the court. To prepare this questionnaire, you will need before you all of the paperwork that you have reg actual preparation of your bankruptcy papers a relatively easy task. You must complete this questionnaire and the related bankruptcy papers with absolute honesty. Any attempts, however minor, to hideete the various bankruptcy forms required by the court. The following Bankruptcy Questionnaire will assist you in this endeavor and should provide you with all of the necessary information to make therecord of what your assets, debts, income and expenses are. Having this information in front of you will help you understand your overall financial position and will eventually be used by you to complInformation Bankruptcy Questionnaire Provided under agreement with copyright holder, © Nova Publishing Company 2004 Before you begin to actually prepare your bankruptcy papers, you must have a clear