General Information
Check the appropriate filing status:
_ Individual: unmarried __ Joint: Living together
_ Individual: married, living apart __ Joint Living apart
___ Individual: married, living together
For DEBTOR:
Have you been a resident of Arizona for the past 180 days? __If married, date of marriage ___________
If divorced, date of divorce First ex-spouse ____________________
Name of ex-spouse ___________________________
Address of ex-spouse _____________________________________________
City _________ State ________ Zip Code _________
ate of divorce Second ex-spouse__________________________
Name of ex-spouse ___________________________
Address of ex-spouse _____________________________________________
City _________ State ________ Zip Code _________
Full Name (no initials) Last Name _________________________________________
First Name _________________________________________
Middle Name_____________________________________________
Any business names used _______________________________
Residence Address: Street Address ________________________________________
City _________State____County ______ Zip Code _______
Mailing Address if different than residence address: _____________________________
City _________State____County ______ Zip Code _______
Length of time at present address ____________________________________________
Other addresses in past 2 years:
From ____ to ____ Address ________________________________________
City ____ State ___ Zip Code _________
Names Used: ____________________________________________________________
From ____ to ____ Address ________________________________________
City ____ State ___ Zip Code _________
Names Used: ____________________________________________________________
From ____ to ____ Address ________________________________________
City ____ State ___ Zip Code _________
Names Used: ____________________________________________________________
Social Security No. ____________Tax I.D. No.____________ Date of Birth: _____________
Home phone number (___) _-____ Work number (___) __ - ____extension ____
y in the past 6 years, enter case number, chapter, District filed in, and
If you have filed another bankruptcy
disposition of the case.________________________________________________________
If your spouse, partner or associate is currently involved in another bankruptcy, enter name of person filing,
relationship to you, case number, chapter, and District filed in.
______________________________________________
Are you in business for yourself (or have been in the last 2 years)? ___Type of business ___________________
Dependents: Name _____________ Age __ Relationship _______________
Name _____________ Age __ Relationship _______________
Name _____________ Age __ Relationship _______________
Name _____________ Age __ Relationship _______________
The debtor or spouse receives support payment for the following dependents:
Name Age Relationship Monthly payment received
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
The debtor or spouses pays support payment for the following dependents:
Name Age Relationship Monthly support paid
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
1st job 2nd job
EMPLOYMENT
Present Occupation: ______________ Present Occupation: ______________
Employer's Name: _______________ Employer's Name: _______________
Address: ______________________ Address: _______________________
City _____ State __ Zip Code ___ City _____ State __ Zip Code __
How long have you been employed? How long have you been employed?
Years __ Months ____ Years _ Months _
Pay period: Weekly __________ Pay period: Weekly ________
Every 2 weeks _____ Every 2 weeks ___
Twice a month _____ Twice a month ___
Monthly __________ Monthly ________
Debtor last 3 pay dates ____ ________ ________
Debtor next 3 pay dates ____ ________ ________
Estimated average current income FOR YOUR PAY PERIOD: 1st job 2nd job
1.Gross pay (wages, salary, commissions).............. ___ ___
2.Estimated additional overtime.............................. ___ ___
3.Withholding and deductions:
Federal withholding tax...... ..................... ___ ___
FICA (social security)............................... ___ ___
Medicare withholding tax......................... ___ ___
State withholding tax............ ................... ___ ___
Insurance.............................. .................... ___ ___
Union dues................................................ ___ ___
Contributions to pension plan................... ___ ___ This will need to be stopped before filing Bankruptcy
Charity......(specify) ______________ ___ ___
Other (specify) __________________ ___ ___
Other Income :
Give estimated monthly income for the following:
Gross average income from business or profession......... _____
Interest and dividends...................................................... _____
Real estate or personal property...................................... _____
Social Security (for your benefit).................................... _____
Social security (for benefit of another)........................... _____
Pension or other retirement income................................ _____
Alimony or spousal maintenance................................... _____
Welfare (include food stamps)....................................... _____
Workman's compensation.............................................. _____
Insurance benefits.......................................................... _____
Unemployment.............................................................. _____
Other (specify) _____________________________ _____
If you anticipate an increase or decrease of more than 10% in any of the above categories within the next year, give
details:
__________________________________________________________________________
__________________________________________________________________________
For SPOUSE
Have you been a resident of Arizona for the past 180 days? _
If married, date of marriage _________________
If divorced, date of divorce First ex-spouse __________________
Name of ex-spouse _________________________
Address of ex-spouse _____________________________________________
City _________ State ________ Zip Code _________
If divorced, date of divorce Second ex-spouse ________________
Name of ex-spouse __________________________
Address of ex-spouse _____________________________________________
City _________ State ________ Zip Code _________
If divorced, date of divorce Third ex-spouse __________________
Name of ex-spouse __________________________
Address of ex-spouse _____________________________________________
City _________ State ________ Zip Code _________
Full Name (no initials) Last Name _________________________________________
First Name _________________________________________
Middle Name _______________________________________
Any other name used ___________________________
Any business names used _________________________
Residence Address: Street Address ____________________________________________
City _________State____County ______ Zip Code ______
Mailing Address if different than residence address: ________________________________
City _________State____County ______ Zip Code ______
Length of time at present address ___________________
Other addresses in past 2 years:
From ____ to ____ Address ___________________________________________
City ____ State ___ Zip Code ________
Names Used: _______________________________________________________________
From ____ to ____ Address ___________________________________________
City ____ State ___ Zip Code ________
Names Used: _______________________________________________________________
From ____ to ____ Address ___________________________________________
City ____ State ___ Zip Code ________
Social Security No. ___________Tax I.D. No.______________ Date of Birth:_______________________
Home phone number (___) _-____ Work number (___) __ - ____extension _______
you have filed another bankruptcy in the past 6 years, enter case number, chapter, District filed in, and
If so disposition of the case._______________________________________________________________
If your spouse, partner or associate is currently involved in another bankruptcy, enter name of person filing,
relationship to you, case number, chapter, and District filed
in.____________________________________________________
Are you in business for yourself (or have been in the last 2 years)? _
Type of business _____________________________________(Restaurant, roofing contractor, baby-sitter at home, etc)
Nature of business _________________________________(Independent contractor, officer of corporation, etc.)
1st job 2nd job
EMPLOYMENT
Present Occupation: ______________ Present Occupation: ______________
Employer's Name: _______________ Employer's Name: _______________
Address: ______________________ Address: _______________________
City _____ State __ Zip Code ___ City _____ State __ Zip Code __
How long have you been employed? How long have you been employed?
Years __ Months ____ Years _ Months _
Pay period: Weekly __________ Pay period: Weekly ________
Every 2 weeks _____ Every 2 weeks ___
Twice a month _____ Twice a month ___
Monthly __________ Monthly ________
Debtor last 3 pay dates ____ ________ ________
Debtor next 3 pay dates ____ ________ ________
Estimated average current income FOR YOUR PAY PERIOD: 1st job 2nd job
1.Gross pay (wages, salary, commissions).............. ___ ___
2.Estimated additional overtime.............................. ___ ___
3.Withholding and deductions:
Federal withholding tax...... ..................... ___ ___
FICA (social security)............................... ___ ___
Medicare withholding tax......................... ___ ___
State withholding tax............ ................... ___ ___
Insurance.............................. .................... ___ ___
Union dues................................................ ___ ___
Contributions to pension plan................... ___ ___ This will need to be stopped before filing Bankruptcy
Charity......(specify) ______________ ___ ___
Other (specify) __________________ ___ ___
Other Income :
Give estimated monthly income for the following:
Gross average income from business or profession......... _____
Interest and dividends...................................................... _____
Real estate or personal property...................................... _____
Social Security (for your benefit).................................... _____
Social security (for benefit of another)........................... _____
Pension or other retirement income................................ _____
Welfare (include food stamps)....................................... _____
Workman's compensation.............................................. _____
Insurance benefits.......................................................... _____
Unemployment.............................................................. _____
Other (specify) _____________________________ _____
If you anticipate an increase or decrease of more than 10% in any of the above categories within the next year, give
details:
Real Property
Present market value $________________
Legal description (from deed)_______________________________________________________
Co-owners Name ____________________________________________________________
Street address _________________________________________________________
City _______ State _____ Zip Code ________
First Mortgage Holder's name: _________________________
Account Number ______________Do you intend to reaffirm this debt ____
Address _____________________________________
City _______ State ____ Zip Code ________
Principal amount owed $ ________________________
Interest Rate _____% Monthly Payment due $ _______
If in arrears, please state the amount in arrears $ ______
Second Mortgage Holder's name: __________________________
Account Number ______________Do you intend to reaffirm this debt ____
Address _____________________________________
City _______ State ____ Zip Code ________
Principal amount owed $ ________________________
Interest Rate _____% Monthly Payment due $ _______
If in arrears, please state the amount in arrears $ ______
Third Mortgage Holder's name: _________________________
Account Number ______________Do you intend to reaffirm this debt ____
Address ______________________________________
City _______ State ____ Zip Code ________
Principal amount owed $ ________________________
nterest Rate _____% Monthly Payment due $ _______
If in arrears, please state the amount in arrears $ ______
Other Real Estate ___________________________________________________________
Street address____________________________________________________________________
Present market value $
________________
Legal description (from deed)_______________
Co-owners Name ___________________________________________________________
Street address ________________________________________________________
City _______ State ____ Zip Code __________
First Mortgage Holder's name: ____________________________
Account Number ______________Do you intend to reaffirm this debt ____
Address _____________________________________
City _______ State ____ Zip Code ________
Principal amount owed $ ________________________
Interest Rate _____% Monthly Payment due $ _______
If in arrears, please state the amount in arrears $ ______
Second Mortgage Holder's name: __________________________
Account Number ______________Do you intend to reaffirm this debt ____
Address _____________________________________
City _______ State ____ Zip Code ________
Principal amount owed $ ________________________
Interest Rate _____% Monthly Payment due $ _______
If in arrears, please state the amount in arrears $ _____
Personal Property
Personal Property
If any of this property was acquired by you or your spouse prior to your marriage, or given to one of you as a gift
or inherited by one of you, be prepared to give details.
1.Checking or savings accounts with banks, credit unions, etc.:
2.Name of Type of Account Account Names(s) on Amount
3.institution number account in account
________________________________________________________________ $________
________________________________________________________________ $________
________________________________________________________________ $________
4. Refundable deposits of money:
5. Deposit with landlord: Amount of Deposit $ _______
Name & address of landlord _____________________________________________
Deposit with utilities: Amount of Deposit $ ________
Name & address of utility ________________________________________________
Deposit with utilities: Amount of Deposit $ ________
Name & address of utility ________________________________________________
6. Household goods and furnishings:
#_____ Televisions(s)...................... @ $_______ each
#_____ Stereo(s)........................... @ $_______ each
#_____ VCR(s).............................. @ $_______ each
#_____ Radio(s)............................ @ $_______ each
#_____ Radio alarm(s)...................... @ $_______ each
#_____ Stove(s)............................ @ $_______ each
#_____ Refrigerator(s)..................... @ $_______ each
#_____ Washer(s)........................... @ $_______ each
#_____ Dryer(s)............................ @ $_______ each
#_____ Microwave(s).................... @ $_______ each
#_____ Vacuum(s)........................... @ $_______ each
#_____ Computer(s)......................... @ $_______ each
#_____ Typewriter(s)....................... @ $_______ each
#_____ Sewing machine(s).................@ $_______ each
TOTAL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $__________
All other household goods and furniture and miscellaneous equipment. $__________
Art objects, stamp, coin and other collections.....................
(describe) ___________________________________ $ ______
. Wearing apparel..................................................................... $__________
_ Wedding/engagement rings...................................... $__________
_ Watches................................................................... $__________
_ Other jewelry (describe)_____________________
__________________________________________ $__________
_ Furs (describe) ________________________ $__________
_ Firearms (describe) ____________________ $__________
#_____ Bicycles................................................................... $__________
Photographic equipment (describe) ______________ $__________
Hobby equipment (describe)________________________ $__________
Sports equipment (describe)________________________ $__________
Musical instruments (describe)______________________ $__________
9. Cash surrender value of life insurance policies
Debtor: Name of life insurance _________________ value $ ______
Spouse: Name of life insurance ________________ value $ ______
10. Annuities (describe) __________________________ $__________
11. Interests in IRA. ERISA, Keogh, or other pension plans
Debtor: Name of plan ________________________ value $ ______
Spouse: Name of plan ________________________ value $ ______
Can you withdraw these funds? _
12. Stocks & interests in incorporated and unincorporated businesses
(describe) _________________________________ value $ ______
13. Interests in partnerships and joint ventures
(describe) _________________________________ value $ ______
14. Bonds (describe) ___________________________ $__________
15. Accounts Receivable (describe)____________________ $__________
16. Alimony, maintenance, support, and property settlements to which you are or may be entitled
(describe) ___________________________________ $__________
17. Other debts owed to you (promissory, tax refund, etc) $__________
18. Equitable or future interests in real property
(describe) _______________________________ $__________
19. Inheritances or life insurance benefits from the estate of a deceased person
(describe) ___________________________________ $ _____
20. Rights to setoff claims............................................................ $__________
21. Patents & copyrights............................................................... $ ______
22. Licenses & franchises............................................................. $__________
23. Automobiles, trucks, trailers, motorcycles motor homes, etc.
a. Year ______ Make _______ Model _________
Body Type _____ Number of doors ____
Number of cylinders ___ Mileage: ______________
Condition of vehicle _____________________________ $ ______
b. Year ______ Make _______ Model _________
Body Type _____ Number of doors ____
Number of cylinders ___ Mileage: ______________
Condition of vehicle _____________________________ $ ______
c. Year ______ Make _______ Model _________
ody Type _____ Number of doors ____
Number of cylinders ___ Mileage: ______________
ondition of vehicle _____________________________ $ ______
d. Year ______ Make _______ Model _________
ody Type _____ Number of doors ____
Number of cylinders ___ Mileage: _____________
ondition of vehicle ____________________________ $ ______
24. Boats, motors & accessories (make, model, and ID#)
___________________________________________________ $ ______
___________________________________________________ $ ______
25. Aircraft & accessories (describe) ________________________ $ ______
26. Office equipment, furnishings, supplies
(describe) __________________________________________ $ ______
27. Machinery, equipment, supplies used in your trade or business
(describe) _________________________________________ $ ______
28. Inventory (describe) _________________________________ $ ______
interivew - 2
29. Valuable animals (describe) ___________________________ $ ______
30. Crops (growing or harvested)............................................................. $ ______
31. Farm equipment & implements.......................................................... $ ______
32. Farm supplies, chemicals, feed.......................................................... $ ______
33. Mobile homes (give year, make, model, VID#) $__________
34. Interests in time-shares (fully paid for)............................................ $__________
35 Deeds of trust (amount owed to you)............................................... $__________
36. Burial plot(s): Location _____________________________
Present market value $_________
Mortgage Holder's name: ___________________________
Account Number ______________Do you intend to reaffirm this debt ____
Address _____________________________________
City _______ State ____ Zip Code ________
Principal amount owed $ ________________________
Interest Rate _____% Monthly Payment due $ _______
f in arrears, please state the amount in arrears $ ______
Other personal property...........................................................................
______________________________________________ $_______
If any of your property is in the possession of someone else, or is wholly or partially titled in the name of someon
else, enter a description of the item, name and address of the other party, and an explanation.
__________________________________________________________________________
__________________________________________________________________________
Creditor Information
If you have a VA or FHA loan on your home, list the VA and FHA office that processed the loan as well as well as th
company to which you make your payments.
If you owe more than one debt to the same creditor, include information about each debt.
If you borrowed money from a finance company, and now are dealing with a different office, you must list each office as a
creditor. This is also true of VA and FHA loans.
If anyone cosigned on an unpaid loan for you, you must list that person as a creditor, as well as the company that made the
loan.
If you have cosigned on an unpaid loan for someone else, you must list that person as a creditor, as well as the company tha
made the loan.
1.Money owed to any branch of the government (for example, Small Business Administration, Social Security
Administration, VA, FHA, DES
2. Money you owe a former spouse (for example, back alimony or child support, property settlement).
3.Back mortgage payments or back rent.
4.Debts secured by deeds of trust.
5.Credit card or revolving charge accounts with banks, oil companies, department stores.
6.Purchase contracts for automobiles, appliances, furniture, etc.
7.Judgments against you. (Include names and addresses of the creditor and creditor's attorney and all co-defendants.)
8.Lawsuits pending against you. (Include names & addresses of the creditor and creditor's attorney and all co-defendants.
9.Debts secured by liens outstanding against any of your property. (Include name & address of person securing lien and
his attorney.
10. Medical bills.
11.Debts for property that has already been repossessed.
12.Loans on which you have cosigned (even if the person you cosigned for is paying the loan).
13.Loans on which someone else has cosigned for you.
14.Loans owed friends and relatives.
15.Loans you obtained for someone else's benefit.
16.Student loans. (Enter names & addresses of the actual creditor, any servicing agent, and the guarantors of the loan.
Include the date when payments on the loan were to begin.)
17.Loans from finance companies.
18.Debts to utility companies.
19.Business debts for which you are or may be liable.
20.Fines and restitution.
21.Unpaid taxes. (Include the dates when the tax returns were filed.)
22.Loans against retirement plans or cash surrender value of life insurance policies.
SECURED CREDITORS:
or each property described, please list information about applicable creditors
list here all creditors who have a right to repossess collateral (including mortgage holders) if you fail to pay the debt.
Item No. Property _______________________________________________________
Creditor: __________________________ Account No. _____________________
Address: _________________________________________________
City ___________ State __________ Zip Code __________
Principal amount owed $ ______ Interest rate _____% Monthly payment $____________
If in arrears please state the amount $___________
Do you intend to reaffirm this debt? _____
Item No. Property _______________________________________________________
Creditor: __________________________ Account No. _____________________
Address: _________________________________________________
City ___________ State __________ Zip Code __________
Principal amount owed $ ______ Interest rate _____% Monthly payment $___________
If in arrears please state the amount $___________
Do you intend to reaffirm this debt? _____
Item No. Property _______________________________________________________
Creditor: __________________________ Account No. _____________________
Address: _________________________________________________
City ___________ State __________ Zip Code __________
Principal amount owed $ ______ Interest rate _____% Monthly payment $____________
If in arrears please state the amount $___________
Do you intend to reaffirm this debt? _____
: List here all agencies to which you owe taxes.
PRIORITY CREDITORS
Type of tax ___________________________ Year incurred _____________________
Creditor Name: ___________________ Account Number __________________
Address: ________________ City __ State ____ Zip Code _______
Principal amount owed $ _________
Collection agency or attorney or servicing agent Name : _____________________________
Address: ________________ City __ State ____ Zip Code _______
Do you dispute this claim? __ If so, state why: ________________________________
Type of tax ___________________________ Year incurred _____________________
Creditor Name:
___________________ Account Number __________________
Address: ________________ City __ State ____ Zip Code _______
Principal amount owed $ _________
Collection agency or attorney or servicing agent Name : _____________________________
Address: ________________ City __ State ____ Zip Code _______
Do you dispute this claim? __ If so, state why: ________________________________
: List here all individuals to whom you owe administrative expenses; alimony,
OTHER PRIORITY CREDITORS
maintenance or support; commitments to capital of bank; deposits you are holding for individuals; employee benefit plans; and
farmers and fisherman
Type of debt ___________________________ Date incurred _____________________
Creditor Name: ___________________ Account Number __________________
Address: ________________ City __ State ____ Zip Code _____________
Principal amount owed $ _________
Collection agency or attorney or servicing agent Name : _____________________________
Address: ________________ City __ State ____ Zip Code _______
Do you dispute this claim? __ If so, state why: _________________________________
Type of debt ___________________________ Date incurred _____________________
Creditor Name: ___________________ Account Number __________________
Address: ________________ City __ State ____ Zip Code _____________
Principal amount owed $ _________
Collection agency or attorney or servicing agent Name : _____________________________
Address: ________________ City __ State ____ Zip Code _______
Do you dispute this claim? __ If so, state why: _________________________________
General Questions About Creditors
Collection Agencies or attorneys are not the actual creditors to whom the debt is owed. We must also have the name and address of creditor(s) they represent.
Title companies (for mortgage payments) or servicing agents (for student loans) are not the actual creditors to whom the debt is owed. We must also have the name and address of the creditor(s) they represent.
Iff your debts were incurred prior to marriage, indicate this on the debt listing sheet, with a notation whet
If an this debt was incurred by the husband or the wife.
1. If you endorsed or signed a check which bounced and is still unpaid, list the person to whom the money is
owed on the Unsecured Creditors Sheet, giving complete information.
2. If anyone ever claimed that you have harmed him or his property willfully or maliciously, give name and
address and details.
____________________________________________________________________
3. If you made any oral or written statements, other than routine information, regarding your financial situation
when you borrowed money or obtained property or credit (for example, financial statements), name and address
and details:
____________________________________________________________________
4. Have you, or your children, or a vehicle titled in your name, within the past 2 years been in any auto accident or
any other accident for which anyone may have a claim against you, or as a result of which you might have a claim
against Anyone? _______________________-
If there has been an auto accident, we will need names and addresses of all drivers and passengers involved and
the owners of any damaged property, and any attorneys or insurance companies involved
We will also need a copy of the police accident report.
Has suit been filed? _
Has there been any settlement made? _
5. If anyone can claim that you have taken money or property by fraud, embezzlement, or misappropriation while
you were a trustee or officer, give name and address and details
____________________________________________________________________
6. Do you owe anything to a former spouse under the terms of a property settlement agreement that was part of
your divorce or legal separation? _______. If yes, list your former spouse as a creditor on the Unsecured Creditors
Sheet. Bring all court papers.
7. Are there community debts that your former spouse agreed to pay in your divorce or legal separation
Agreement? _ If yes, list all such creditors on the Unsecured Creditor Sheet, giving complete information.
Bring all court papers
8. If you are borrowing the money to pay the attorney's fees and filing fees for this bankruptcy, list the lender on
the Unsecured Creditor Sheet.
9. Are you required to make any payments for alimony, child support or spousal maintenance, or spouse's
attorney's fees? __. If yes, what is the amount of the attorney's Fees? $_____
How much per month? $________ Amount in arrears on these payments? $ _______
List the person whom you owe on Unsecured Creditor Sheet.
10. Do you now have a VA insured Mortgage? ___ or FHA insured Mortgage? ____
11. Have you ever sold any property in which the mortgages were assumed rather than paid off? ___. If yes, give
Name and address of mortgage holder ______________________________________________
Was this mortgage guaranteed by the VA? _ FHA? _
12. Have you ever had a property taken by foreclosure, or given a deed in lieu of foreclosure?____ If yes, give
Names and addresses of all mortgage holders
__________________________________
Was this mortgage guaranteed by the VA? _ FHA? _
13. Are there any unpaid court judgments entered against you? ____ enter names and addresses of these creditors
and their attorneys on the Unsecured Creditors List.
14. Do YOU owe anyone any wages, salaries or commissions which were earned within the last 3 months? ___ If
yes, enter these creditors on the Priority Creditors List.
15. Have
you filed all required tax returns (State and Federal Income, sales, withholding, unemployment, etc) from
the current years on back? ____
If no, list below the tax returns not filed and for which year(s):_______________________________________________
16. If IRS or any other taxing authorities have a lien against your property, give details.
17. Do you have a student loan? ____ If yes, list name and address of the lender, any servicing agent, and the
government agency which guaranteed the loan on the Unsecured Creditor Sheet. Indicate the date on which
payments were to start.
18. Are you current in your mortgage payment? ___
Has a trustee (foreclosure) sale been set? ___Date of trustee sale ________________
Name, address and phone number of trustee __________________________________
______________________________________
19. Are you current on your Homeowners Association payments? ___ If Not,
Amount in arrears $____________ List this creditor on Unsecured Creditors Sheet.
20. Are you current on your vehicle payments? ______. If not,
Vehicle Number 1_________________________________ Months in arrears _____
Account Number ________________ Do you intend to reaffirm this debt? ____
Principal amount owed $ _____ Interest rate __ % Monthly Payment $______
Creditors Name ___________________________
Address: ________________________________
City __________ State _____ Zip Code ____
Vehicle Number 2 ______________________________ Months in arrears _____
Account Number __________________ Do you intend to reaffirm this debt ___
Principal amount owed $ _____ Interest Rate __% Monthly Payment $_______
Creditors Name ___________________________
Address: ________________________________
City __________ State _____ Zip Code ____
21. Have you used any charge cards in the past 120 days? _____. If yes, enter name(s) of cards, date used, amount
of purchase or cash advance, items purchased and the purpose of a cash advance.
Card Name __________ Card Number _____________date of purchase ________
Item purchased _______________________________________________________
Card Name __________ Card Number _____________date of purchase ________
Item purchased _______________________________________________________
Card Name __________ Card Number _____________date of purchase ________
Item purchased _______________________________________________________
Card Name __________ Card Number _____________date of purchase ________
Item purchased _______________________________________________________
Card Name __________ Card Number _____________date of purchase ________
Item purchased _______________________________________________________
Card Name __________ Card Number _____________date of purchase ________
Item purchased _______________________________________________________
22. Have you made any contributions to a retirement account in the last 120 days?_____. If yes, enter date and
amount contributed. ______________________
List here all other creditors.
UNSECURED CREDITORS:
_______________ Account No. ___________________________
Creditor's name:
Address: ___________________ City ________ State __ Zip Code _
Type of debt: _________________ Principal Amount Owed: $______________
Collection agency or attorney or servicing agent name: ________________________
Address: __________________ City ________ State ___ Zip Code _
do you dispute this claim? __ if yes, state the reason: ___________________________
Creditor's name: _______________ Account No. ___________________________
Address: ___________________ City ________ State __ Zip Code _
Type of debt: _________________ Principal Amount Owed: $______________
Collection agency or attorney or servicing agent name: ________________________
Address: __________________ City ________ State ___ Zip Code _
do you dispute this claim? __ if yes, state the reason: ___________________________
Creditor's name: _______________ Account No. ___________________________
Address: ___________________ City ________ State __ Zip Code _
Type of debt: _________________ Principal Amount Owed: $______________
Collection agency or attorney or servicing agent name: ________________________
Address: __________________ City ________ State ___ Zip Code _
do you dispute this claim? __ if yes, state the reason: ___________________________
Creditor's name: _______________ Account No. ___________________________
Address: ___________________ City ________ State __ Zip Code _
Type of debt: _________________ Principal Amount Owed: $______________
Collection agency or attorney or servicing agent name: ________________________
Address: __________________ City ________ State ___ Zip Code _
do you dispute this claim? __ if yes, state the reason: ___________________________
Creditor's name: _______________ Account No. ___________________________
Address: ___________________ City ________ State __ Zip Code _
Type of debt: _________________ Principal Amount Owed: $______________
Collection agency or attorney or servicing agent name: ________________________
Address: __________________ City ________ State ___ Zip Code _
do
you dispute this claim? __ if yes, state the reason: ___________________________
Creditor's name: _______________ Account No. ___________________________
Address: ___________________ City ________ State __ Zip Code _
Type of debt: _________________ Principal Amount Owed: $______________
Collection agency or attorney or servicing agent name: ________________________
Address: __________________ City ________ State ___ Zip Code _
do you dispute this claim? __ if yes, state the reason: ___________________________
Rental and Lease Agreements
Property being leased ________________________________
Account Number ___________________________________
Name of other party _________________________________
Address: __________________________________________
City ____ State ___ Zip Code ___________
Date signed ________________ Amount per month $__________
Length of time the lease is to run _____________
Intend to keep this lease? Yes____ No____
Property being leased ________________________________
Account Number ___________________________________
Name of other party _________________________________
Address: __________________________________________
City ____ State ___ Zip Code ___________
Date signed ________________ Amount per month $__________
Length of time the lease is to run _____________
Intend to keep this lease? Yes____ No____
Property being leased ________________________________
Account Number ___________________________________
Name of other party _________________________________
Address: __________________________________________
City ____ State ___ Zip Code ___________
Date signed ________________ Amount per month $__________
Length of time the lease is to run _____________
Intend to keep this lease? Yes____ No____
Contracts For Sale of Real Property
Type of contract (realtor, agreement of sale, etc.) _____________________
Name of other party __________________________ Account No. _______________
Address: _______________________________________
City _______ State _____ Zip Code: _________
Date agreement was signed _________________________
Property involved _______________________________________________________
Terms of the contract ____________________________________________________
Intend to keep this contract? Yes____ No____
Type of contract (realtor, agreement of sale, etc.) _____________________
Name of other party __________________________ Account No. _______________
Address: _______________________________________
City _______ State _____ Zip Code: _________
Date agreement was signed _________________________
Property involved _______________________________________________________
Terms of the contract ____________________________________________________
Intend to keep this contract? Yes____ No____
TIME SHARE:
Name of other party ____________________Account No. _____________________
Address: ______________________City ______ State ____ Zip Code __
Date agreement was signed ______________________________________________
Property involved _______________________________________________________
Number of weeks per year you may use this time-share __________________________
Terms of the contract ___________________________________________________
CO DEBTORS:
Debts for which you cosigned, or promised to pay someone else's debt if he did not pay:
Name of the creditor ___________________ Account Number ___________________
Address of creditors: ______________ City ___ State __ Zip Code _
Name of the person you cosigned for _______________________
Address of co-signor ________________ City _ State _ Zip Code __
Name of the creditor ___________________ Account Number ___________________
Address of creditors: ______________ City ___ State __ Zip Code _
Name of the person you cosigned for _______________________
Address of co-signor ________________ City _ State _ Zip Code __
Current Expenditures
Give estimated average monthly expenditures:
Home expenses:
Rent ( ) or ( ) first mortgage....................... $ _____
Second mortgage........................................ $ _____
Third mortgage........................................... $ _____
Homeowners Association Fee $ _____ Utilities:
Electricity and gas...................................... $ _____
Water/sewer............................................... $ _____
Telephone.................................................. $ _____
Garbage...................................................... $ _____
Security...................................................... $ _____
Cable.......................................................... $ _____
Pest Control .............................................. $ _____
Other expenses:
Home maintenance (if you own your home) $ _____
Food.......................................................... $ _____
Clothing.................................................... $ _____
Laundry and dry cleaning......................... $ _____
Medical, dental, medicines....................... $ ______
Transportation (gas & oil, repairs)............ $ _____
Parking/bus (if no vehicle)........................ $__________
ecreation, clubs and entertainment,
newspapers, magazines, etc.................. $ _____
haritable contributions (not deducted from wages)............ $ _____
surance: Not deducted from wages
Auto........................................................... $ _____
Homeowner's or renter's (not included in mortgage).................................. $ _____
Life ........................................................... $ _____
Health ....................................................... $ _____
Other (describe)_____________________ $ _____
Taxes (not deducted from wages or included above):
Property taxes (not included in mortgage).. $________
Estimated income tax.................................. $________
Payment on back taxes................................ $ ____
Other (describe)_____________________ $ ____
Installment payments:
Vehicle ( ) installment or ( ) lease............... $________
Vehicle ( ) installment or ( ) lease............... $________
Vehicle ( ) installment or ( ) lease............... $ ___
Other (describe)_____________________ $________
Miscellaneous other expenses:
Support of dependents not living at home do not include child support payments here)$ ____
Average expenses from operation of a business profession, or farm............ $ ____
Student loans............................................... $ ____
Child care.................................................... $ ____
Education (include tuition & books)........... $ ____
Union & professional dues (not deducted from wages)............. $ ____
Rental of appliances or furniture (describe) $ ____
Other (describe)_____________________ $ ____
Other (describe)_____________________ $ ____
Current Monthly Business Expenses
Business name: ________________Nature of business: ______________________________ Owner: Debtor ___
Spouse _ Joint _ Average monthly income.....................$ ______
Rent/mortgage........................... $ _______
Repairs and upkeep................... $ _______
Electricity/gas............................ $ _______
Water/sewer............................... $ _______
Telephone.................................. $ _______
Garbage..................................... $ _______
Security..................................... $ _______
Other utilities............................ $ _______
Insurance................................... $ _______
Taxes......................................... $ _______
Installment payments on equipment $___________
Rental/lease payments on equipment... $ _______
Maintenance of equipment................... $ _______
Advertising........................................... $ _______
Bank service charges............................ $ _______
Office expenses.................................... $ _______
Dues and publications.......................... $ _______
Laundry or dry cleaning....................... $ _______
Supplies and materials......................... $ _______
Freight.................................................. $ _______
Travel and entertainment..................... $ _______
Wages and salaries............................... $ _______
Commissions........................................ $ _______
Employee benefit plans........................ $___________
Pension/profit sharing plans................. $ _______
Production costs................................... $ _______
Vehicle expenses.................................. $ _______
Professional Services (Accountant, Lawyer) $ _______
Licenses................................................ $ _______
Other (describe): ________________ $ _______
TOTAL EXPENSES: $ ______
Statement of Financial Affairs
1.
Income from employment or business:
2.
Income from other sources:
Income debtor has received this calendar year 2006 $_____________
Income debtor received last calendar year 2005 $_____________
Income debtor received the prior calendar year 2004 $_____________
Income spouse has received this calendar year 2003 $_____________
Income spouse received last calendar year 2004 $_____________
Income spouse received the prior calendar year 2003 $_____________
Income debtor has received this calendar year 2006 from other sources $___________
Source ____________________________________
Income debtor has received last calendar year 2005 from other sources $___________
Source ____________________________________
3. List all payments to creditors of more than $600 made within the past 90 days.
Creditor Name Address Amount Paid Reason Date Amount Still owing $ ______
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
List all payments made within the past year to creditors who are, or were, insiders, such as relatives.
Creditor Name Relationship Address Amount Paid Reason Date Amount Still owing $ __
__________________________________________________________________________
__________________________________________________________________________
4. List all lawsuits in which you are or were involved within the past year, including divorce. Give name and
location of court case, name, case number, and the decision of the court (judgment). If no judgment yet, write
"pending". Bing all court documents
Lawsuit No. 1 ______________________________________________________________
____________________________________________________________________
Lawsuit No. 2 ______________________________________________________________
____________________________________________________________________
Lawsuit No. 3 ______________________________________________________________
____________________________________________________________________
5. List all wa
ges that have been garnished and all property that has had a lien placed on it by any creditor within
the past year. Include name and address of creditor and description of the property.
__________________________________________________________________________
__________________________________________________________________________
6. List all party that has been repossessed by a creditor, sold at foreclosure by a creditor, transferred by a deed in
y returned to a seller within the past year. Include name and address of the
lieu of foreclosure, or voluntaril
creditor, description of the property, date of repossession, value of of property and method of repossession.
__________________________________________________________________________
__________________________________________________________________________
7. List all propert
income produced by property that you own. Include name and address of creditor and description of property.
_________________________________________________________________________
__________________________________________________________________________
8. List all propert
y which has been in the hands of a receiver or court appointed official within the past year.
Include name and address of receiver and description of property.
_________________________________________________________________________
__________________________________________________________________________
9. List all gifts whose value is more than $200 that you have given to family members in the past year. List all
charitable contributions of more than $100 in the past year. Include name and address of recipient, date of gift and
description or dollar amount of gift.
_________________________________________________________________________
__________________________________________________________________________
10. List all losses from fire or theft or other casualty property or money lost, date of loss and the circumstances of the loss. Indicate if the loss was recovered by insurance.
_________________________________________________________________________
11. List all payments made within the past year to attorneys or other persons for consultation or work done
concering debt consolidation or bankruptcy. Include the name and address, amount of payment and date of
payment.
Amount paid within the past year to Consumer Credit Counseling, if any $ _______
12. List all property transferred in the past year (property sold, pension plans or IRA's cashed in, vehicles traded
in, property put up as security for a loan). Include name and address of the person to whom transfer was made,
date of transfer, how much money was received in return and what you did with the money received.
_________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
13. List all bank accounts or credit union accounts which were closed during the past year. Include name and
address of bank, type of account, account number, date of closing and ending balance.
14. List all safe deposit boxes in which you have kept securities, cash, or other valuables during the past year. Include name
and address of bank and a description of the contents.
__________________________________________________________________________
__________________________________________________________________________________________________
15. List any set offs made by any creditor during the past 90 days. A set off occurs when you and your creditor both have
claims against each other. Examples: bank seized our bank account for payment of a debt or IRS seized your tax refund for
payment against back taxes. List name and address of creditor and the amount of set off.
__________________________________________________________________________
__________________________________________________________________________________________________
16. List any property owned by another person which is in your physical possession or control. List any property that you are
borrowing, any property that you are storing for someone else, any property belonging to someone else who shares your home. Also any real or personal property or bank accounts belonging to someone else for which the title is wholly or partially in your name. Include name and address of the actual owner of the property, description and value of the property, and an explanation of the situation.
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
_________________________________________________________________________
17. If the debtor resides or resided in a community property state, commonwealth, or territory (including Alaska, Arizona,
California, Idaho, Louisiana, Nevada, New Mexico, Puerto Rico, Texas, Washington, or Wisconsin) within the 6 year period immediately preceding the commencement of the case, identify the name of the debtor's spouse and of any former spouse who resides or resided with the debtor in the community property state.
__________________________________________________________________________________________________
18. For the purpose of this questions, the following definitions apply:
"Environmental Law" means any federal, state, or local statute or regulation regulating pollution, contamination,
releases of hazardous or toxic substances, wastes or material into the air, land, soil, surface water, groundwater, or other medium, including, but not limited to, statutes or regulations regulating the cleanup of these substances, wastes, or material. "Site" means any location, facility, or property as defined under any Environmental Law, whether or not presently or formerly owned or operated by the debtor, including, but not limited to, disposal sites. "Hazardous Material" means anything defined as hazardous waste, hazardous substance, toxic substance, hazardous material, pollutant, or contaminant or similar term under an Environmental Law.
A. List the name and address of every site for which the debtor has received notice in writing by a governmental unit that it may be liable or potentially liable under or in violation of an Environmental Law. Indicate the governmental unit, the date of the notice, and, if known, the Environmental Law.
Site Name and Address: ________________________________________________
____________________________________________________________________
Name and Address of Governmental Unit: _________________________________
____________________________________________________________________
________________________________________________________
Date of Notice:
______________________________________________________
Environmental Law:
B. List the name and address of every site for which the debtor provided notice to a governmental unit of a release of governmental unit to which the notice was sent and the date of the notice.
Hazardous Material. Indicate the
Site Name and Address: ________________________________________________
_________________________________
Name and Address of Governmental Unit:
____________________________________________________________________
____________________________________________________________
Date of Notice:
______________________________________________________
Environmental Law:
C. List all judicial or administrative proceedings, including settlements or orders, under any Environmental Law with respect to which the debtor is or was a party. Indicate the name and address of the governmental unit that is or was a party to the proceeding, and the docket number.
_________________________________
Name and Address of Governmental Unit:
____________________________________________________________________
______________________________________________________
Docket Number:
__________________________________________________
Status or Disposition:
19. If you own any property that may be a threat of imminent and identifiable harm to public safety, please indicate below:
__________________________________________________________________________________________________
Business Information
20. List the names and addresses of all such businesses, the nature of the business (listed above), and beginning and ending dates.
__________________________________________________________________________
___________________________________________________________________________
21. List all bookkeepers or accountants who kept or supervised books of accounts or business records within the past 6 years.
Include name & address and dates.
___________________________________________________________________________
_____________________________________________________________________________
List all firms or individuals who have audited business books or records, or prepared a financial statement, within
List all financial institutions or creditors to whom a financial statement was issued within the past 2
years. Enter name & address.
___________________________________________________________________________
__________________________________________________________________________
22. List the dates of the last 2 inventories taken of your property, the name of the person who supervised each inventory, and the past 2 years. Enter name & address.
_____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
List all firms or individuals who are in possession of business books or records. Enter name & address.
Partnership and Corporations
Partnership and Corporations
23. If the filing is for a partnership, list the names and addresses, the nature and percentage of partnership interest of partnership. each member of the partnership or corporation
____________________________________________________________________________
____________________________________________________________________________
__________________________________________________________________________
If the filing is for a corporation, list all officers and directors of the corporation, and each stockholder who directly
or indirectly owns, controls or holds 5 percent or more of the voting securities of the corporation. List the name
and address, title, and nature and percentage of stock ownership.
_____________________________________________________________________________
__________________________________________________________________________________________________
24. If the filing is for a partnership, list each member who withdrew from the partnership within one year immediately preceding the commencement of this case. List the name and address and date of withdrawal.
If filing is for a corporation, list all officers or directors whose relationship with the corporation terminated within
one year immediately preceding the commencement of this case. List the name and address, title and date of
termination.
__________________________________________________________________________________________________
including for a partnership or corporation, list all withdrawals or distributions credited or given to an insider
25. If the filing within a year, compensation in any form, bonuses, loans, stock redemptions, options exercised and any other perquisite within one year immediately preceding the commencement of this case. List the name and address of recipient, relationship to you, the date and purpose of withdrawal, and the amount of money or description and value of withdrawal.
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