My Bankruptcy Questionnaire

Instructions:

Bankruptcy Questionnaire

Real Property/Real Estate

Personal Property

Your Debts

Employment & Income Information

Your Monthly Expenses

Leases and Executory Contracts

Statement of Financial Affairs

Miscellaneous Informantion

Bankruptcy Questionnaire

Page 1 of 9
Instructions:

Before completing this questionnaire, gather all documents listed on the Document Checklist that was emailed to you and save your files in .pdf format (preferred). Uploaded documents cannot be cut off (all four corners of the page must be visible), all text must be crisp and legible, and files must be provided in .pdf, .docx, or .jpg format). If you need to upload multiple files for one question, save all of those files to one .zip folder and upload the .zip folder. If you need to stop and return to the questionnaire at a later time, you can save your progress by clicking the "Save" button located at the bottom of the page. Please note that we do not ask for any information and documentation that does not need to be provided to the Bankruptcy Court. Answer all questions in their entirety.
I understand that by completing this form, I may be providing sensitive information. I consent to the electronic transmission of the information that I am providing herein.
Use your mouse to sign your name below. If both you and your spouse are filing bankruptcy together, at least one of you must sign below. *
TIP: Use your keyboard's TAB key to navigate to the next field.
1. Enter your name. If you are married and filing bankruptcy jointly with your spouse, his/her information will be entered separately, below.*

First NameMiddle InitialLast NameSuffix (Jr., Sr., II, III)
1A. If you or your business has used any other names in the last eight (8) years, please enter them below. Include maiden and previous married names, name variations, also known as (AKA), formerly known as (FKA), doing business as (DBA), and formerly doing business as (FDBA). If this question does not apply, enter None or N/A:*
2. Enter your date of birth (MM/DD/YY)*
Never marriedMarriedSeparatedDivorcedCommon law (in states where recognized: CO, IA, KS, MT, NH, SC, TX, UT)Widowed
YesNo
3B. Enter your spouse's name:*

First NameMiddle InitialLast NameSuffix (Jr., Sr., II, III)
3C. If your spouse or your spouse's business has used any other names in the last eight (8) years, please enter them below. Include maiden and previous married names, name variations, also known as (AKA), formerly known as (FKA), doing business as (DBA), and formerly doing business as (FDBA). If this question does not apply, enter None or N/A:*
3D. Enter your spouse's date of birth (MM/DD/YY):*
4. Enter your full residential address, including apartment/unit number and zip code:*

Street Address

Street Address Line 2

CityState

Zip Code
5. If you have a separate mailing address, enter it here. This is the address that the U.S. Bankruptcy Court will use to notify you of your bankruptcy matters.

Street Address

Street Address Line 2

CityState

Zip Code
6. Enter the county of the state where you currently reside: *
YesNo
YesNo

YesNo
8C. Enter your spouse's full address, including apartment/unit number and zip code:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
8D. Enter the county of the state where your spouse currently resides:*
9. Enter your phone number(s) for contact purposes. Communication regarding this questionnaire may be conducted via phone.*
10. Enter your email address for contact purposes. Communication regarding this questionnaire may be conducted via email.*
Chapter 7Chapter 11Chapter 13Other
YesNo

YesNo

YesNo

Rows	ENTER FULL ADDRESS OF YOUR PREVIOUS RESIDENCE, INCLUDING APT/UNIT NO. AND ZIP CODE:	PROVIDE BEGINNING AND END DATES OF RESIDENCY (MONTH/YEAR TO MONTH/YEAR):
PREVIOUS ADDRESS #1:
PREVIOUS ADDRESS #2:
PREVIOUS ADDRESS #3:

Rows	NAMES OF ALL PERSON(S) WHO FILED:	BANKRUPTCY CHAPTER FILED:	CITY/STATE WHERE BANKRUPTCY WAS FILED:	DATE THAT THE BANKRUPTCY CASE WAS FILED (MONTH/YEAR):
PREVIOUS FILING #1:

Rows	FULL NAME OF THE PERSON/BUSINESS FILING BANKRUPTCY:	THE FILING PARTY'S RELATIONSHIP TO YOU:	DATE THAT THE BANKRUPTCY CASE WAS FILED (if known):	THE BANKRUPTCY FILING DISTRICT (city/state):
RELATED/ PENDING CASE INFORMATION:

Rows	FULL PROPERTY ADDRESS:	LIST NAMES OF ALL PROPERTY OWNERS ON THE DEED:	PROPERTY'S FAIR MARKET VALUE/APPRAISAL VALUE: ($)	NAMES OF ALL MORTGAGE HOLDERS/LIEN HOLDERS ON THE PROPERTY:	ARE PAYMENTS CURRENT/BEHIND/ PAID OFF?:	INTEREST RATE FOR EACH LOAN (Chapter 13 cases only):	KEEP/SURRENDER PROPERTY?:
PRIMARY RESIDENCE/SINGLE FAMILY HOME:

Rows	FULL PROPERTY ADDRESS:	LIST NAMES OF ALL PROPERTY OWNERS ON THE DEED:	PROPERTY'S FAIR MARKET VALUE/APPRAISAL VALUE: ($)	NAMES OF ALL MORTGAGE HOLDERS/LIEN HOLDERS ON THE PROPERTY:	ARE PAYMENTS CURRENT/BEHIND/ PAID OFF?:	INTEREST RATE FOR EACH LOAN (Chapter 13 cases only):	KEEP/SURRENDER PROPERTY?:
SECOND HOME/SECONDARY RESIDENCE:

Rows	FULL PROPERTY ADDRESS:	LIST NAMES OF ALL PROPERTY OWNERS ON THE DEED:	PROPERTY'S FAIR MARKET VALUE/APPRAISAL VALUE: ($)	NAMES OF ALL MORTGAGE HOLDERS/LIEN HOLDERS ON THE PROPERTY:	ARE PAYMENTS CURRENT/BEHIND/ PAID OFF?:	INTEREST RATE FOR EACH LOAN (Chapter 13 cases only):	KEEP/SURRENDER PROPERTY?:
CABIN/VACATION HOME:

Rows	FULL PROPERTY ADDRESS:	LIST NAMES OF ALL PROPERTY OWNERS ON THE DEED:	PROPERTY'S FAIR MARKET VALUE/APPRAISAL VALUE: ($)	NAMES OF ALL MORTGAGE HOLDERS/LIEN HOLDERS ON THE PROPERTY:	ARE PAYMENTS CURRENT/BEHIND/ PAID OFF?:	INTEREST RATE FOR EACH LOAN (Chapter 13 cases only):	KEEP/SURRENDER PROPERTY?:
DUPLEX/MULTI-UNIT BUILDING:

Rows	FULL PROPERTY ADDRESS:	LIST NAMES OF ALL PROPERTY OWNERS ON THE DEED:	PROPERTY'S FAIR MARKET VALUE/APPRAISAL VALUE: ($)	NAMES OF ALL MORTGAGE HOLDERS/LIEN HOLDERS ON THE PROPERTY:	ARE PAYMENTS CURRENT/BEHIND/ PAID OFF?:	INTEREST RATE FOR EACH LOAN (Chapter 13 cases only):	KEEP/SURRENDER PROPERTY?:
CONDOMINIUM/ COOPERATIVE:

Rows	FULL PROPERTY ADDRESS:	LIST NAMES OF ALL PROPERTY OWNERS ON THE DEED:	PROPERTY'S FAIR MARKET VALUE/APPRAISAL VALUE: ($)	NAMES OF ALL MORTGAGE HOLDERS/LIEN HOLDERS ON THE PROPERTY:	ARE PAYMENTS CURRENT/BEHIND/ PAID OFF?:	INTEREST RATE FOR EACH LOAN (Chapter 13 cases only):	KEEP/SURRENDER PROPERTY?:
MOBILE/MANUFACTURED HOME:

Rows	FULL PROPERTY ADDRESS:	LIST NAMES OF ALL PROPERTY OWNERS ON THE DEED:	PROPERTY'S FAIR MARKET VALUE/APPRAISAL VALUE: ($)	NAMES OF ALL MORTGAGE HOLDERS/LIEN HOLDERS ON THE PROPERTY:	ARE PAYMENTS CURRENT/BEHIND/ PAID OFF?:	INTEREST RATE FOR EACH LOAN (Chapter 13 cases only):	KEEP/SURRENDER PROPERTY?:
VACANT LAND:

Rows	FULL PROPERTY ADDRESS:	LIST NAMES OF ALL PROPERTY OWNERS ON THE DEED:	PROPERTY'S FAIR MARKET VALUE/APPRAISAL VALUE: ($)	NAMES OF ALL MORTGAGE HOLDERS/LIEN HOLDERS ON PROPERTY:	ARE PAYMENTS CURRENT/BEHIND/ PAID OFF?:	INTEREST RATE FOR EACH LOAN (Chapter 13 cases only):	KEEP/SURRENDER PROPERTY?:
VACATION TIMESHARE:

Rows	PLOT LOCATION/ ADDRESS:	LIST NAMES OF ALL PROPERTY OWNERS ON THE DEED:	FAIR MARKET VALUE: ($)	NAMES OF ALL LIEN HOLDERS ON THE PROPERTY:	ARE PAYMENTS CURRENT/BEHIND/ PAID OFF?:	INTEREST RATE FOR EACH LOAN (Chapter 13 cases only):	KEEP/SURRENDER PROPERTY?:
CEMETERY PLOT:

Rows	FULL PROPERTY ADDRESS:	LIST NAMES OF ALL PROPERTY OWNERS ON THE DEED:	PROPERTY'S FAIR MARKET VALUE/APPRAISAL VALUE: ($)	NAMES OF ALL MORTGAGE HOLDERS/LIEN HOLDERS ON THE PROPERTY:	ARE PAYMENTS CURRENT/BEHIND/ PAID OFF?:	INTEREST RATE FOR EACH LOAN (Chapter 13 cases only):	KEEP/SURRENDER PROPERTY?:
LIFE ESTATE:

Rows	NAME OF LANDLORD/RENTAL AGENCY:	ADDRESS OF LANDLORD/RENTAL AGENCY:	SCHEDULED EVICTION DATE (MM/DD/YY):
EVICTION INFORMATION:

Rows	BRIEFLY DESCRIBE THE HAZARD:	IF IMMEDIATE ATTENTION IS NEEDED, EXPLAIN WHY:	ENTER FULL ADDRESS OF PROPERTY WHERE HAZARD IS LOCATED:
HAZARD/PROPERTY REQUIRING ATTENTION:

Rows	VALUE IN CURRENT CONDITION: ($)	WHOSE ASSET?:
HOUSEHOLD GOODS & FURNISHINGS (furniture, major appliances, and general household possessions):

Rows	VALUE IN CURRENT CONDITION ($):	WHOSE ASSET?:
MISCELLANEOUS ELECTRONICS (televisions, DVD players/BLU RAY/VCRs, desktop computers, laptop computers, printers, cell phones, tablets, e-readers, digital music players, game consoles, stereos, etc.)

Rows	DESCRIPTION;	VALUE: ($)	WHOSE ASSET?:
COLLECTIBLES:

Rows	SPECIFY TYPE OF EQUIPMENT OR INSTRUMENTS/ DESCRIPTION:	VALUE: ($)	WHOSE ASSET?:
SPORTS, PHOTOGRAPHIC, EXERCISE, OR HOBBY EQUIPMENT/ MUSICAL INSTRUMENTS:

Rows	SPECIFY TYPE/ DESCRIPTION:	VALUE: ($)	WHOSE ASSET?:
FIREARMS:

Rows	VALUE: ($)	WHOSE ASSET?:
CLOTHING:

Rows	SPECIFY TYPE/DESCRIPTION:	VALUE: ($)	WHOSE ASSET?:
JEWELRY:

Rows	SPECIFY TYPE/DESCRIPTION:	VALUE: ($)	WHOSE ASSET?:
PETS/ANIMALS:

Rows	SPECIFY TYPE/DESCRIPTION:	VALUE: ($)	WHOSE ASSET?:
HEALTH AIDS:

Rows	SPECIFY TYPE/ DESCRIPTION:	VALUE: ($)	WHOSE ASSET?:
YARD TOOLS AND EQUIPMENT:

Rows	VALUE: ($)	WHOSE ASSET?:
CASH ON HAND:

Rows	DESCRIPTION OF ITEMS:	VALUE: ($)	WHOSE ASSET?:
OFFICE EQUIPMENT, FURNISHINGS, AND SUPPLIES:

Rows	DESCRIPTION OF ITEMS:	VALUE: ($)	WHOSE ASSET?:
MACHINERY, FIXTURES, EQUIPMENT, BUSINESS SUPPLIES, AND TOOLS OF YOUR TRADE:

Page 4 of 9
Your Debts

The below questions apply to all persons filing bankruptcy.
19. Do you have bills to upload? This includes statements for your credit card debts, collection notices, medical bills, personal loans/loans to family members or friends, payday loans, past due utility bills, lawsuits and civil judgments, vehicle repossession debts, bank overdrafts and NSF fees, tax debts and tax liens, student loans, past due child support/alimony, overpayments of Social Security and unemployment compensation benefits, mortgage foreclosures, and Sheriff Sale notices.*

Yes, I will upload them here.No. By checking this box, I am certifying that I do not possess statements for any of my debts, and I understand that: a) I remain solely responsible for providing the information regarding my debts, and b) all of my debts must be listed in my bankruptcy paperwork.
19A. Upload your bills here. Provide only the MOST RECENT statement for each of your bills, including the most recent statement from all collection agencies collecting on a debt. Statements must show: a) the name and address of the creditor, b) the amount owed, c) the account number, if available, and d) the name of the person who owes the debt. REVIEW EACH PAGE OF YOUR SCANNED BILL STATEMENTS PRIOR TO UPLOADING TO ENSURE THAT EACH BILL WAS SCANNED AND THE STATEMENTS ARE LEGIBLE. BILLS THAT CANNOT BE READ WILL NOT BE INCLUDED IN YOUR PAPERWORK.*

Browse Files

Cancelof
YesNo
20A. Upload your credit report(s) here. If you have more than one credit report to provide, save all credit reports to a .zip folder and upload the .zip folder here:*

Browse Files

Cancelof
YesNo
21A. Upload your additional credit report(s) here:*

Browse Files

Cancelof

Page 6 of 9
Your Monthly Expenses

Provide the following information regarding your monthly household expenses.
DIRECTIONS: List the MONTHLY amounts for your household expenses. If you are married and living with your spouse, include all of your spouse's expenses, even if he/she is not filing bankruptcy with you. Also list the expenses you pay for your dependents.

If you have expenses that are quarterly, such as utility payments (i.e., water, natural gas, etc.), divide your quarterly payment by 3 to estimate an average monthly expense.

If you have any other expenses throughout the year that are not monthly, estimate the total annual amount spent and divide that number by 12 to calculate an average monthly expense.
Note: If your spouse is filing bankruptcy with you AND resides at a different address, provide your spouse's separate household expenses in questions 39, 40, and 41, below.

35. Provide your MONTHLY housing expenses. Fill out all fields. If an expense does not apply, enter "N/A" or "0":*

Rows	MONTHLY EXPENSE: ($)
RENT:
1ST MORTGAGE:
2ND MORTGAGE/ HOME EQUITY LINE OF CREDIT:
ADDITIONAL MORTGAGES:
REAL ESTATE/PROPERTY TAXES (do NOT list taxes here if they are included/escrowed in the mortgage payment listed above):
PROPERTY/HOMEOWNER'S/RENTER'S INSURANCE (do NOT list insurance payments if they are included/escrowed in the mortgage payment listed above):
HOME MAINTENANCE, REPAIRS, AND UPKEEP:
HOMEOWNER'S ASSOCIATION OR CONDO DUES:
ELECTRICITY & HOME HEATING (electric, natural gas, propane, kerosene, etc.):
WATER, SEWAGE, AND GARBAGE:
TELEPHONE, CELL PHONE, INTERNET, CABLE, AND SATELLITE SERVICES:

36. Provide your MONTHLY living expenses. Fill out all fields. If an expense does not apply, enter "N/A" or "0":*

Rows	MONTHLY EXPENSE: ($)
FOOD, GROCERIES, AND HOUSEKEEPING SUPPLIES:
CHILDCARE AND CHILDREN'S EDUCATION COSTS:
CLOTHING, LAUNDRY, AND DRY CLEANING:
PERSONAL CARE PRODUCTS AND SERVICES (cosmetics, toiletries, health care items, haircuts, etc. not already accounted for):
MEDICAL AND DENTAL EXPENSES (OUT-OF-POCKET ONLY for over-the-counter and miscellaneous medical and dental costs; do NOT include your payroll deductions for medical/dental/vision expenses. Do not include medical insurance payments here.):
TRANSPORTATION (gasoline, auto maintenance, registrations, bus/train/taxi fares, EZ Pass, etc.):
ENTERTAINMENT, CLUBS, GYM MEMBERSHIP, RECREATION, NEWSPAPERS, MAGAZINES, AND BOOKS:
CHARITABLE AND RELIGIOUS DONATIONS:
PET FOOD/VETERINARY CARE:
CIGARETTES/TOBACCO EXPENSES:
STORAGE UNIT:

37. Provide your MONTHLY living expenses. Fill out all fields. If an expense does not apply, enter "N/A" or "0":*

Rows	MONTHLY EXPENSE: ($)
LIFE INSURANCE (OUT-OF-POCKET ONLY; do NOT list payroll deductions):
HEALTH INSURANCE (OUT-OF-POCKET ONLY; do NOT list payroll deductions):
VEHICLE INSURANCE (all vehicles):
OTHER INSURANCE (provide the TYPE OF INSURANCE and the monthly amount):
TAX PAYMENTS (IRS, state, local, self-employment, etc.) (provide the TYPE OF TAX PAYMENT and the monthly amount):
CAR PAYMENT (Vehicle 1; can be for a financed or leased vehicle):
CAR PAYMENT (Vehicle 2; can be for a financed or leased vehicle):
CAR PAYMENT (Vehicle 3; can be for a financed or leased vehicle):
OTHER VEHICLE PAYMENTS (if more than 1, list each payment individually and indicate the vehicle. Include other vehicles, such as boats, ATVs, RVs, motorcycles, etc.):
ALIMONY/CHILD SUPPORT PAYMENTS YOU MAKE (do NOT include amounts deducted from paycheck):
PAYMENTS TO SUPPORT OTHERS NOT LIVING WITH YOU (provide monthly amount and indicate who you are supporting):
STUDENT LOANS (do NOT list payments for loans currently in forbearance or deferment or deducted from paycheck):
OTHER EXPENSES (indicate TYPE OF EXPENSE and the monthly amount. Do NOT list credit card payments or payments for any unsecured debts that will be included in your bankruptcy):

YesNo

41. Provide YOUR SPOUSE'S MONTHLY living expenses. Fill out all fields. If an expense does not apply, enter "N/A" or "0":*

Rows	MONTHLY EXPENSE: ($)
LIFE INSURANCE (OUT-OF-POCKET ONLY; do NOT list payroll deductions):
HEALTH INSURANCE (OUT-OF-POCKET ONLY; do NOT list payroll deductions):
VEHICLE INSURANCE (all vehicles):
OTHER INSURANCE (provide the TYPE OF INSURANCE and the monthly amount):
TAX PAYMENTS (IRS, state, local, self-employment, etc.) (provide the TYPE OF TAX PAYMENT and the monthly amount):
CAR PAYMENT (Vehicle 1; can be for a financed or leased vehicle):
CAR PAYMENT (Vehicle 2; can be for a financed or leased vehicle):
CAR PAYMENT (Vehicle 3; can be for a financed or leased vehicle):
OTHER VEHICLE PAYMENTS (if more than 1, list each payment individually and indicate the vehicle. Include other vehicles, such as boats, ATVs, RVs, motorcycles, etc.):
ALIMONY/CHILD SUPPORT PAYMENTS YOU MAKE (do NOT include amounts deducted from paycheck):
PAYMENTS TO SUPPORT OTHERS NOT LIVING WITH YOU (provide monthly amount and indicate who you are supporting):
STUDENT LOANS (do NOT list payments for loans currently in forbearance or deferment or deducted from paycheck):
OTHER EXPENSES (indicate TYPE OF EXPENSE and the monthly amount. Do NOT list any credit card payments or payments for any unsecured debts that will be included in your bankruptcy):

Rows	WHO IS THE PLAN WITH? (List the employer's name/ financial institution):	INDICATE THE TYPE OF PLAN (IRA, 401(k), 403(b), pension, etc.):	CURRENT VALUE: ($)	WHOSE ASSET?:	NOT APPLICABLE:
RETIREMENT PLAN #1:
RETIREMENT PLAN #2:
RETIREMENT PLAN #3:
RETIREMENT PLAN #4:
RETIREMENT PLAN #5:

Rows	SPECIFY TYPE OF ASSET (bonds, mutual funds, stocks):	DESCRIBE ASSET (quantity and description of bonds, stocks, etc.):	VALUE: ($)	WHOSE ASSET?:	NOT APPLICABLE:
BONDS, MUTUAL FUNDS, PUBLICLY/ NON-PUBLICLY TRADED STOCK ASSET #1:
ASSET #2:
ASSET #3:

TYPE OF ACCOUNT:

NAME OF BANK:

CURRENT BALANCE: ($)

NAMES OF ALL ACCOUNT HOLDERS:

DESCRIPTION (optional):

NOT APPLICABLE:

ACCOUNT #1:

ACCOUNT #2:

ACCOUNT #3:

ACCOUNT #4:

ACCOUNT #5:

Rows	SPECIFY TYPE OF BOND & DESCRIPTION/QUANTITY:	VALUE: ($)	WHOSE ASSET?:	NOT APPLICABLE:
BOND ASSET #1:
BOND ASSET #2:
BOND ASSET #3:

Rows	NAME OF THE ANNUITY PROVIDER (insurance company/annuity provider):	THE PAYOUT INTERVAL (monthly, annually, etc.):	VALUE: ($)	WHOSE ASSET?:	NOT APPLICABLE:
ANNUITY #1:
ANNUITY #2:
ANNUITY #3:

Rows	TYPE OF PLAN (EDU IRA, SECTION 529/530, ABLE, STATE TUITION):	WHO IS PLAN WITH? (LIST THE AGENCY/ STATE/ INSTITUTION NAME):	VALUE: ($)	WHOSE ASSET?:	NOT APPLICABLE:
EDUCATION PLAN #1:
EDUCATION PLAN #2:
EDUCATION PLAN #3:

Rows	NAME OF LANDLORD OR UTILITY COMPANY:	AMOUNT OF THE SECURITY DEPOSIT: ($)	WHOSE PROPERTY?:
SECURITY DEPOSIT #1:
SECURITY DEPOSIT #2:
SECURITY DEPOSIT #3:

Rows	INDICATE TYPE OF PREPAYMENT (rent, layaway, gift card):	DESCRIPTION OF THE PREPAYMENT:	AMOUNT OF THE PREPAYMENTS: ($)	WHOSE PROPERTY?:
PREPAYMENT #1:
PREPAYMENT #2:
PREPAYMENT #3:

Rows	INDICATE THE YEAR FOR WHICH YOU ARE OWED OR ANTICIPATE A TAX REFUND:	INDICATE IF THIS IS A FEDERAL, STATE, OR LOCAL TAX REFUND:	AMOUNT OF THE TAX REFUND OWED TO YOU (estimate if unknown): ($)	WHOSE PROPERTY?:
TAX REFUND #1:
TAX REFUND #2:
TAX REFUND #3:

Rows	INDICATE THE TYPE OF SUPPORT OWED (alimony, child support, etc.):	INDICATE WHO OWES YOU THE ALIMONY/CHILD SUPPORT:	AMOUNT OF THE ALIMONY OR CHILD SUPPORT OWED TO YOU: ($)	WHOSE PROPERTY?:
ALIMONY/CHILD SUPPORT OWED TO YOU #1:
ALIMONY/CHILD SUPPORT OWED TO YOU #2
ALIMONY/CHILD SUPPORT OWED TO YOU #3:

Rows	INDICATE WHAT TYPE OF MONEY IS OWED (unpaid wages, disability benefits, etc.):	WHO OWES YOU THE MONEY?:	AMOUNT OWED TO YOU: ($)	WHOSE PROPERTY?:
AMOUNTS OWED TO YOU #1:
AMOUNTS OWED TO YOU #2:
AMOUNTS OWED TO YOU #3:

Rows	INDICATE TYPE OF ASSET (trust, life estate, future/equitable interest):	DESCRIPTION OF ASSET:	VALUE OF ASSET: ($)	WHOSE PROPERTY?:
TRUSTS/ESTATES/FUTURE INTEREST #1:
TRUSTS/ESTATES/FUTURE INTEREST #2:
TRUSTS/ESTATES/FUTURE INTEREST #3:

Rows	INDICATE TYPE OF ASSET (inheritance, estate distribution, or death benefit):	DESCRIPTION OF ASSET:	AMOUNT OF ASSET: ($)	WHOSE PROPERTY?:
INHERITANCE, ESTATE DISTRIBUTIONS, & DEATH BENEFITS #1:
INHERITANCE, ESTATE DISTRIBUTIONS, & DEATH BENEFITS #2:
INHERITANCE, ESTATE DISTRIBUTIONS, & DEATH BENEFITS #3:

Rows	INDICATE TYPE OF ASSET (patent, copyright, trademark, trade secret, other intellectual property):	DESCRIPTION OF ASSET:	VALUE OF ASSET, IF ANY: ($)	WHOSE PROPERTY?:
INTELLECTUAL PROPERTY/TRADE SECRETS #1:
INTELLECTUAL PROPERTY/TRADE SECRETS #2:
INTELLECTUAL PROPERTY/TRADE SECRETS #3:

Rows	INDICATE TYPE OF ASSET (license, franchise, other intangible):	DESCRIPTION OF ASSET:	VALUE OF ASSET, IF ANY: ($)	WHOSE PROPERTY?:
LICENSES, FRANCHISES, & OTHER INTANGIBLES #1:
LICENSES, FRANCHISES, & OTHER INTANGIBLES #2:
LICENSES, FRANCHISES, & OTHER INTANGIBLES #3:

Rows	DESCRIPTION OF THE CLAIM OR AWARD:	WHO OWES YOU THE MONEY?:	AMOUNT OF CLAIM OR AWARD: ($)	WHOSE PROPERTY?:
PERSONAL INJURY CLAIM & AWARD #1:
PERSONAL INJURY CLAIM & AWARD #2:
PERSONAL INJURY CLAIM & AWARD #3:

Rows	WHO ARE YOU SUING:	TYPE OF LAWSUIT	REASON FOR THE LAWSUIT:	ANTICIPATED CLAIM/AWARD AMOUNT: ($)	WHO IS THE SUING PARTY?:
LAWSUIT #1:
LAWSUIT #2:
LAWSUIT #3:

Rows	REASON FOR THE CLAIM:	TYPE OF CLAIM/LAWSUIT	WHO IS THE CLAIM AGAINST?:	ANTICIPATED CLAIM/AWARD AMOUNT: ($)	WHO IS THE PLAINTIFF (SUING PARTY)?:
CLAIM #1:
CLAIM #2:
CLAIM #3:

Rows	DESCRIPTION OF INVENTORY:	VALUE: ($)	WHOSE ASSET?:
BUSINESS INVENTORY:

Rows	TYPE OF BUSINESS INTEREST (CORPORATION, LLC, PARTNERSHIP, JOINT VENTURE):	NAME OF THE BUSINESS:	PERCENTAGE/DESCRIPTION OF YOUR INTEREST IN THE BUSINESS:	VALUE OF THE BUSINESS: ($)	WHOSE INTEREST?:	NOT APPLICABLE:
BUSINES, CORPORATION, LLC, PARTNERSHIP, AND JOINT VENTURE INTEREST #1:
INTEREST #2:
INTEREST #3:

Rows	INDICATE IF YOU HAVE ACCOUNTS RECEIVABLE, OR EARNED COMMISSIONS:	WHO OWES YOU THE MONEY?:	VALUE: ($)	WHOSE ASSET?:
ACCOUNTS RECEIVABLE OR EARNED COMMISSIONS:

Rows	INDICATE IF YOU HAVE CUSTOMER LISTS, OR MAILING LISTS:	VALUE: ($)	WHOSE ASSET?:
CUSTOMER LISTS OR MAILING LISTS:

Rows	DESCRIPTION OF OTHER BUSINESS-RELATED PROPERTY NOT ALREADY LISTED:	VALUE: ($)	WHOSE ASSET?:
OTHER BUSINESS-RELATED PROPERTY:

Rows	DESCRIPTION OF FARM ANIMALS (TYPE & QUANTITY):	VALUE: ($)	WHOSE ASSET?:
FARM ANIMALS:

Rows	DESCRIPTION OF CROPS:	VALUE: ($)	WHOSE ASSET?:
CROPS, GROWING AND HARVESTED

Rows	DESCRIPTION OF EQUIPMENT, IMPLEMENTS, MACHINERY, FIXTURES, AND TOOLS OF YOUR TRADE (TYPE & QUANTITY):	VALUE: ($)	WHOSE ASSET?:
FARM & COMMERCIAL FISHING EQUIPMENT, IMPLEMENTS, MACHINERY, FIXTURES, AND TOOLS OF YOUR TRADE:

Rows	DESCRIPTION OF FARM & COMMERCIAL FISHING SUPPLIES, CHEMICALS, AND FEED (TYPE & QUANTITY):	VALUE: ($)	WHOSE ASSET?:
FARM & COMMERCIAL FISHING SUPPLIES, CHEMICALS, AND FEED:

Rows	DESCRIPTION OF OTHER PROPERTY:	VALUE: ($)	WHOSE ASSET?:	NOT APPLICABLE:
OTHER PROPERTY:
OTHER PROPERTY:
OTHER PROPERTY:

Rows	LIST VEHICLE YEAR, MAKE, MODEL & STYLE:	ENTER YOUR VEHICLE MILEAGE:	VEHICLE CONDITION (excellent, very good, good, fair, inoperable):	LIST NAMES OF ALL PERSONS ON VEHICLE TITLE:	IS VEHICLE FINANCED, LEASED, PAID OFF?:	ARE LOAN/LEASE PAYMENTS CURRENT OR BEHIND?:	KEEP OR SURRENDER VEHICLE?:
VEHICLE #1

Rows	NAME OF EMPLOYER:	ADDRESS OF EMPLOYER:	JOB TITLE:	HOW LONG EMPLOYED THERE:	NOT APPLICABLE:
SOURCE OF INCOME #1:
SOURCE OF INCOME #2:
SOURCE OF INCOME #3:

Rows	DEPENDENT'S RELATIONSHIP TO YOU:	DEPENDENT'S AGE:	IS CHILD A PART-TIME, LIVE-IN DEPENDENT PER A CUSTODY ARRANGEMENT? IF SO, PROVIDE DETAILS:	NOT APPLICABLE:
DEPENDENT #1:
DEPENDENT #2:
DEPENDENT #3:
DEPENDENT #4:
DEPENDENT #5:

Rows	NAMES OF ALL PERSON(S) CONTRIBUTING MONEY:	INDICATE THE CONTRIBUTOR'S RELATIONSHIP TO YOU:	THE AVERGE MONTHLY AMOUNT CONTRIBUTED: ($)	REASON FOR THE CONTRIBUTION:
CONTRIBUTOR:

Rows	REASON FOR THE CHANGE IN INCOME:	WHO EXPECTS THE INCREASE OR DECREASE:	NOT APPLICABLE:
Expected INCREASE
Expected DECREASE: