Bankruptcy Questionnaire

Home » Bankruptcy Questionnaire

Bankruptcy Questionnaire

Step 1 of 14 - Personal Information

In order to prepare your petition, please complete the following Questionnaire and provide ALL of the applicable documents listed in the Document Checklist. Upon receipt, your paralegal will schedule an intake interview with you to prepare your petition. Please be absolutely candid and provide as much information as possible; too much information is better than too little. As your Attorneys, we ask that you be open and candid, so that we can give you the best advice possible. If you withhold information from us because you are embarrassed or don’t want to disclose all of your assets and/or debts, we cannot effectively represent you. Further, it is a crime if you don’t list all your assets and debts. It’s simply not worth the jail time to withhold information. In addition, providing false information is grounds for us to withdraw from your case. We will take every measure to ensure that your information is strictly confidential and protected by the attorney- client privilege and the attorney work-product privilege. The information and documents will be used for the sole purpose of drafting your Petition, Statements, Schedules, and related documents. PLEASE ANSWER ALL QUESTIONS: IF NOT APPLICABLE, PUT N/A. DO NOT LEAVE QUESTIONS UNANSWERED. It is critical that you list ALL of you creditors. TO ENSURE THAT ALL YOUR CREDITORS ARE LISTED, OBTAIN A FREE COPY OF YOUR CREDIT REPORT If you move, you must provide our office and the Trustee with the updated contact information. Some bankruptcies can last years. As a result, your attorney must always be able to contact you, especially in case of a deadline. Because people sometimes forget to update contact information, we ask that you provide us with long-term contact information. These people will only be contacted if we cannot locate you directly. These people will not be told the nature or purpose for the contact.
Instructions Reviewed: By checking the box below you certify that you have read and understand the above instructions regarding the completion of this Questionnaire.*
- Yes

Save and Continue Later

Personal Information
Full Name*
First Middle Last
AKA
List all of the names in addition to the name above you have used to obtain credit.
Phone*
Email*
Social Security Number*
Date of Birth*
MM slash DD slash YYYY
Full Address*
Street Address Address Line 2 City State ZIP Code
Mailing Address
Street Address Address Line 2 City State ZIP Code
Marital Status*
Prior Bankruptcies*
Who is Filing?*

Save and Continue Later

Spouse Name*
First Middle Last
Spouse AKA*
List all of the names in addition to the name above you have used to obtain credit.
Spouse Phone*
Spouse Email*
Spouse Social Security Number*
Spouse Date of Birth*
MM slash DD slash YYYY
Spouse Address
Street Address Address Line 2 City State ZIP Code

Enter if different

Save and Continue Later

Household Information
Do You have financial dependants living with you?*
Number in Household (You and all dependents)*
Please enter a number from 1 to 30.
Dependants Living With You*
Name Age Relationship
Do you have a domestic support obligation*
Select yes if one or more of the debtors who will be filing has a legal obligation to pay child support or alimony.
DSO Payments*
Name Address Monthly Amount Arrears

List all people to whom a domestic support obligation is due (child support or alimony).
Do You Owe Taxes?
Hidden
Taxes*
IRS State Other
Case Issues
Have Your Wages Been Garnished in the Past 3 months?*
- Yes
- No
Garnishing Creditor*
Creditor Name Creditor Address Creditor Fax Creditor Email

Enter the information regarding the creditor who is garnishing your wages.
Garnished Employer*
HR Contact Name HR Address HR Fax HR Email

Enter the information regarding your employer whose wages have been garnished.
Do You Have a Foreclosure Sale Pending?*
- Yes
- No
Scheduled Foreclosure Date*
MM slash DD slash YYYY
Foreclosure Creditor*
Creditor Name Creditor Address Creditor Fax Creditor Email

Enter the information regarding the creditor who is threatening Foreclosure.
Is a Creditor Threatening Repossession?*
- Yes
- No
Repossession Creditor*
Creditor Name Creditor Address Creditor Fax Creditor Email

Enter the information regarding the creditor who is threatening Repossession.

Save and Continue Later

Please enter ALL of your property and its approximate value. The value should be the lowest reasonable value like the yard-sale value. A response is required for each question. If you do not have property in the group, enter "none" and "0" for the value.
Real Estate
Real Estate, Residence, Building, Land, Timeshares*
Location Value Amount Owed $
Mortgage Loans*
Description Lender Monthly Payment Interest Rate Keep/Surrender Amount Past Due
Automobiles, Boats, Motorcycles, SUVs, Tractors
Automobiles/Boats/Motorcycles*
Year Make Model Trim Mileage VIN Value $ Amount Owed $
Auto Loans*
Description Lender Monthly Payment Interest Rate Keep/Surrender Amount Past Due
Watercraft/Aircraft/Recreational/Other Vehicles*
Year Make Model Value $ Amount Owed $
Personal Property
Large Kitchen Appliances (Fridge, Microwave, Freezer, Stove, etc.)*
Description Quantity Yard-sale Value

Washer, dryer, fridge, freezer, stove, microwave, sewing machines.
Carpets*
Quantity Yard-sale Value Notes

All carpets in use
Beds & Bedding*
Quantity Yard-sale Value
Provisions*
Quantity Yard-sale Value Notes

Stock of food and necessary supplies for 1 year
Dining & Kitchen Tables & Chairs*
Quantity Yard-sale Value Notes
Sofas/Chairs & Related Furniture*
Quantity Yard-sale Value

Enter dressers, couches and chairs, shelves, coffee table, end tables, lamps, household tools, desks kitchenware
Bedroom Furniture (other than beds & Bedding)*
Description Quantity Yard-sale Value
Dressers*
Quantity Yard-sale Value
End-tables, Entertainment centers, Hutches, Coffee tables*
Description Quantity Yard-sale Value
Lamps, Mirrors, Vanity*
Description Quantity Yard-sale Value
Household Tools*
Description Quantity Yard-sale Value

Vacuum, hand tools, etc.
Desks*
Quantity Yard-sale Value
Kitchen Appliances, Cookware, Dishes, & Utencils*
Description Quantity Yard-sale Value
Game Tabless (Pool, ping pong, etc.)*
Description Quantity Yard-sale Value
Yard Accesories (BBQ, fire pit, heaters)*
Description Quantity Yard-sale Value
Yard Tools & Equipment (lawmower, hoes, rakes, shovels, etc.)*
Description Quantity Yard-sale Value
Electronics (Televisions, Stereo, DVD Players, Computer, Printer, etc)*
Description Quantity Yard-sale Value
Books, Music, Instruments, Pictures, Artwork, Stamp Collections*
Description Quantity Yard-sale Value
Recreational Equipment (bikes, skis, etc.)*
Description Quantity Yard-sale Value
Firearms & Ammunition*
Description Quantity Yard-sale Value
Wearing Apparel (clothing)*
Description Quantity Yard-sale Value
Jewelry*
Description Quantity Yard-sale Value
Miscellaneous Items*
Description Quantity Yard-sale Value
Checking, Savings, Cash & Cash Accounts*
Account Type (Checking, Savings, Pre-paid, etc.) Institution Account # Amount
Stocks/Bonds/CD/Money Market*
Account Type Institution Amount
Education Savings Plans or State Tuition Plans*
Account Type Institution Owner Present Value
Retirement Accounts
Account Type Institution Amount

401(k), IRA, Pension or other
Life Insurance Policies*
Policy Type Institution Beneficiary Cash Value

Save and Continue Later

Business Information
Do You or Your Spouse Have A Business?*
- Yes
- No
Business Name*
Entity Type*
Business Address*
Street Address Address Line 2 City State ZIP Code
Do you have the right to sue anyone for money?*
- Yes
- No
Business Owners*
Owner % Ownership
Date You Began The Business*
MM slash DD slash YYYY
Do You Have any Current Contracts or Leases?*
- Yes
- No

Save and Continue Later

Executory Contracts
Contracts & Leases*
Description Name Address Keep or

Save and Continue Later

Income
Employment Status*
Employer*
Income*
Self/Spouse Employer Gross Monthly Amount
Employer Address*
Street Address Address Line 2 City State ZIP Code
Pay Frequency*

Save and Continue Later

Spouse's Income Information
Spouse Employment Status*
Spouse Employer*
Spouse Employer Address*
Street Address Address Line 2 City State ZIP Code

Save and Continue Later

Monthly Budget
This section deals with your household monthly budget. Please indicate the total amount for each monthly expense. If the monthly amount varies, please use an average over the past 6 months.
Rent or Mortgage Expense*
Property, homeowner or renter insurance*
Real Estate Taxes*
Home maintenance, repairs & upkeep*
HOA Dues or Condo Fees*
Additional mortgage or home equity loan payment*
Utilities - Electricity, heat, & natural gas*
Water, Sewer, & garbage*
Telephone, cell phones, cable, satellite & internet*
Other Utilites*
Food & Housekeeping Supplies*
Childcare & children's educatin costs*
Clothing*
Laundry/Dry Cleaning*
Personal Care Products & Services*
Medical & Dental Expenses*
Transportation (fuel, bus, train, but not auto loans)*
Entertainment, Clubs, Recreation, & Newspapers*
Charitable Contributions & Religious Donations*
Life Insurance*
Health Insurance*
Vehicle Insurance*
Other Insurance*
Taxes (that are not deducted from your wages)*
Installment or Lease Payments
Description Comments Amount
Alimony, maintenance & Support (not deducted from pay)*
Other Support Payments*
Other Monthly Expenses
Description Comments Amount

Save and Continue Later

Prior Addresses for the past 3 years
Address City State Zip
In the past 8 years, have you lived in Arizona, California, Idaho, Louisiana, Nevada, New Mexico, Puerto Rico, Washington, or Wisconsin?*
- Yes
- No
Other Income in Past 2 Years*
Year Amount Source Recipient

List income received other than business or job received , even if not taxable, that you have received from alimony, child support, social security, unemployment, other public benefits, pensions, rental income, dividends, lawsuits, royalties, gambling or lottery winnings.
Payments To Creditors*
Creditor Date(s) of Payment(s) Total Paid

List the total of all payments to each creditor that totals $600 or more in the past 90 days.
Payments to Insiders in Past 1 Year*
Creditor Date(s) of Payment(s) Total Amount

Insiders include your relatives, any general partners, or relatives of any general partners,
Payment or Transfers within 1 Year made that benefitted an Insider.*

See definition of insider above.
Lawsuits, court action, or administrative proceeding in past year.*
Case Caption Case No. Status

List all matters, including personal injuries, small claims, collection suits, paternity actions, divorce, child support, and contract disputes.
Property Repossessed, Foreclosed, Garnished, Attached, Seized or Levied within 1 year.*
Creditor Property Taken Property Value
Within 90 days set off of any amount from your account or refuse to make a payment because you owed a debt.*
Creditor Description Amount Date
Property taken within 1 year in possession of an assignee for the benefit of creditors, court-appointed receiver, custodian, or another official.*
Creditor Amount Description
Gifts of $600 or more given to any person within past 2 years.*
Name Relationship Date(s) Amount
Charitable Contributions of $600 or more*
Recipient Description Relationship Date(s) Total Amount
Property Losses within 1 Year caused by fire, theft, or other disaster, or gambling.*
Description of Property Date of Loss Value of Property
Payments for Bankruptcy*
Party Date(s) of Transfer Amount

List any payments you or someone else on your behalf has paid or transferred any property to anyone you consulted with about filing bankruptcy.
Payments for Dealing with Creditors*
Party Date(s) of Transfer Amount

List any payments you or someone else on your behalf has paid or transferred any property to anyone who promised to help you deal with creditors or to make payments to your creditors.

Save and Continue Later

Statements regarding your financial affairs.
List all property transfers, including property sold or trades to any person in the past 2 years.*
Party Relationship Date(s) Value

List both outright transfers and transfers made as security to any person in the ordinary course of business. (Don't include any gifts or transfers already listed under another question.
Transfers to a self-settled trust in the past 10 years where you are a beneficiary.*
Trust Name Date Property Value Received
Financial Accounts or Instruments that were closed, sold, moved, or transferred within past 1 Year.*
Institution Type of Acount Balance Date of Closing

Include checking, savings, money market, or other financial accounts, certificates of deposit, shares in banks, credit unions, or other financial institutions.
Safe Deposit Box or other depository*
Institution Parties with Access Description Value of Contents

Safe places to store securities, cash or other valuables.
Property In your Possession or Control that someone else owns.*
Owner Description Value of Property Location

Include property you borrowed from, are storing for, or hold in trust for someone else.
Environmental Liability*
Location Governmental Unit Date of Notice Environmental Law

List property that you have been notified by a governmental unit that you may be liable or potentially liable under or in violation of an environmental law.
Release of Hazardous Material*
Location Governmental Unit Date of Notice Environmental Law

List all instances where you have notified a governmental unit of a release of hazardous material (hazardous waste, substance, toxic substance, pollutant, or contaminant or similar term under environmental law.
Judicial or Administrative Proceedings in which you were a party under any environmental law.*
Case Name Case Number Status
Businesses you have owned in the past 4 years.*
Business Business Type Nature of Business Start Date End Date
Business Financial Statements Provided in past 2 years.*
Institution Date

Save and Continue Later

Name*
First Last
Hidden
Full Name*
Phone*
Email*
Practice Area*
- You agree to the Terms, Conditions & Disclaimer.
Email
This field is for validation purposes and should be left unchanged.

Name	Age	Relationship

Name	Address	Monthly Amount	Arrears

IRS	State	Other

Creditor Name	Creditor Address	Creditor Fax	Creditor Email

Bankruptcy Questionnaire

Bankruptcy Questionnaire

Step 1 of 14 - Personal Information

Personal Information

Household Information

Case Issues

Real Estate

Automobiles, Boats, Motorcycles, SUVs, Tractors

Personal Property

Business Information

Executory Contracts

Income

Spouse's Income Information

Monthly Budget