This is our questionnaire I am working on creating. I must learn some more.

CASE INFORMATION

How are you filing? Individual ____ Husband & Wife _____

Which chapter are you filing? 7 ____13 _____

Have you filed in the past eight years? _____ Where? ________ Case Number__________

DEBTOR

Name: ________________________ Phone _________________ Email _______________

also known as in last eight years:__________________________

previously known as in past eight years: __________________________________

Social Security Number: __________________________

Physical Address:____________________________, _____________, CA ________

Mailing Address:____________________________, _____________, CA ________

SINGLE _____ DIVORCED _____ MARRIED _____ LEGAL SEPARATION_____

LIVE WITH SPOUSE, FILING JOINT WITH SPOUSE____

SEPARATED FROM SPOUSE, FILING JOINT WITH SPOUSE____

LIVE WITH SPOUSE, SPOUSE NOT FILING_____

SEPARATED FROM SPOUSE, SPOUSE NOT FILING____

Not filing Joint – skip to the next section

Name:___________________________________________Phone: _________________

aka:__________________________ fka: __________________________________

Social Security Number: __________________________

Mailing Address:____________________________, _____________, CA ________

EXECUTORY CONTRACTS

NOT A PURCHASE OR LOAN!

Do you have any Executory Contracts/Leases or ongoing agreements in which something more than just payment of money remains to be done. Include all leases – apartment, car, water softner, etc. 

BUDGET INFORMATION

DEBTOR Occupation:___________________Employer ___________________ How Long?_____

Work Address:__________________________, _____________, CA ________

SPOUSE Occupation:________________ Employer _____________________ How Long? _______

Work Address:__________________________, _____________, CA ________

CIRCLE Marital Status married OR single OR divorced OR separated

PROPERTY

Please complete the following by placing the value of the property listed below to the right of the property plus other information listed (use a separate sheet of paper if needed --- put zero if you one but of no value, put NONE if you do not own one add space for other property 

Security Deposit with landlord or utility company amount  --- if more than three attached list with name, address of deposit and amount

$ ______ Interest in Insurance Policies. Name of Insurance Company of each policy and itemize surrender or refund value of each.

$_______ Annuities, itemize, and name each issuer. Name of Annuity, policy number, $_______ Interests in IRA, ERISA, Keogh, or other pension or profit sharing. Itemize. Stock and interests in incorporation and unincorporated businesses. Interests in partnership or joint ventures. Details on back 

$_______ Government or corporate bonds and other negotiable and non-negotiable instruments details

$_______ Accounts Receivable from__________

$_______ Alimony, maintenance, support, and property settlements owed by______________

$_______ Tax Refund due to YOU by IRS (Federal) _____ FTB (State) _____

$_______ Liquidated debts owed to debtor 

$_______ Contingent and un-liquidated claims of every nature, including tax refunds, counterclaims of the debtor, and rights to setoff claims

$_______ Patents, copyrights, and other intellectual property. Give particulars.$_______

Vehicles, Trailers, Plans, Boats, Etc

$________ Office equipment, furnishings, supplies type______________________

$_______ Machinery, fixtures, equipment and supplies used in businesses type _______________ $_______ Inventory

$_______ Animals type _________

$_______ Crops – growing or harvested. Give particulars

$_______ Framing equipment and implements $_______ Farm supplies, chemicals, and feed 

$_______ Other personal property of any kind not already listed.

HOME YOU OWN - NOT RENT

BEDROOM ____ BATHS ________ SQUARE FEET ________

PROPERTY MARKET VALUE AMOUNT $___________________

STATEMENT OF FINANCIAL AFFAIRS

All Previous Income

Have you made a payment during the last ninety days on loans, installments, purchases or other debts, that add up to more than $600 for any one creditor? ________ 

Please attach an explanation if you answer yes to the following: 

Have you made a payment during the last 12 months on loans, installments, purchases or other debts for the benefit of insiders?______

Do you have any suits, administrative proceedings, executions, garnishments or attachments that you were a party to within one year immediately preceding the filing of this bankruptcy case? ______ 

Did you have any property attached, garnished, or seized under any legal or equitable process within one year immediately preceding the commencement of this case? ______ 

Was any property repossessed by a creditor, sold at a foreclosure sale, transferred through a deed in lieu of foreclosure or return to the seller, during the last 12 months? ______

Was any property the assignment of property for the benefit of creditors in the last 120 days? ______ 

Has any property been in the hands of a custodian, receiver, or court-appointed official during the last 12 months?______ 

Have you given any gifts to family members worth over $200 or charitable contributions over $100 in the past 12 months? ______ 

Have you suffered any losses from fire, theft or gambling in the past 12 months? ______ 

Have you closed out any checking, savings, or other financial account in your name or held for your benefit, which were closed, sold, or otherwise transferred during the past 12 months? ______

Do you have a safe deposit or other box or depository in which the debtor has or had securities, cash, or other valuables during the last 12 months? ___________

Has any setoffs been made by any creditor, including a bank, against a debt or deposit of the debtor, during the past 90 days? __________

Is there any property that is owned by another person, yet you hold control? __________ 

List any previous marriages in the past eight years? Add additional on reverse

Have you moved in the 3 years? List all previous addresses

INTENTIONS

What are your plans with your secured property?

Reaffirm, Surrender, Redeem Other __________ Type of Property_______________________

Reaffirm, Surrender, Redeem Other __________ Type of Property_______________________

Reaffirm, Surrender, Redeem Other __________ Type of Property_______________________

Reaffirm, Surrender, Redeem Other __________ Type of Property_______________________

MEANS TEST

Please complete for the last six months – not current month!

DO YOU HAVE YOUR PRE-BANKRUPTCY CERTIFICATE? YES OR NO

ACKNOWLEDGE: I am aware I must obtain a post-bankruptcy certificate also!

BUSINESS PROPERTY

BUSINESS PROFIT AND LOSS

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