Bankruptcy Questionnaire

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Bankruptcy Questionnaire

CONFIDENTIAL - OFFICE USE ONLY
INSTRUCTIONS: The purpose of the Bankruptcy Questionnaire is to address all issues pertinent to seeking bankruptcy protection. It is important to be as complete as possible but for purposes of the initial consultation, you should not stress over having absolutely exact information. Simply do your best from the top of your head and from readily available information. Your attorney will go over this information with you and discuss what items will need more detail or elaboration. Your answers will help enable your attorney to provide an informed opinion as to your financial situation and determine if bankruptcy is an appropriate solution and if so, what chapter of bankruptcy relief would be appropriate. If you are in doubt or have any questions with regard to a question on the Questionnaire, leave it blank your attorney will explain it and cover it with you. Should you have any questions in completing the Questionnaire, do not hesitate to contact the office.

Federal law requires full and honest disclosure of all assets, debts and answers to various inquiries of the bankruptcy schedules, Statement of Financial Affairs and the Statement of Current Monthly Income and Means Test. Failure to provide truthful answers and disclosures may result in civil or criminal prosecution. These forms are for INTERNAL USE ONLY of Lewis Legal Services, P.C. and all sensitive information provided is protected by the attorney-client relationship and will be used for the sole purpose of assessing your financial situation and preparation of the bankruptcy petition and supporting schedules.
What is your current marital status?

SingleMarriedMarried but SeparatedMarried, Divorce pendingDivorced within last 3 yearsCohabitation / Living with boyfriend/girlfriendOther
Social Security Number (last 4 digits)*
Individual
Social Security Number (last 4 digits)*
Spouse
Do you or your spouse have any dependents?*

YesNo

Employer Name and Address (Your Employment)

Name of Employer

Work Address (where you go to work)

CityState

Zip Code

Employment Information

	Detail
Job Title / Position
Start Date or Length of Employment
Gross earnings per year (estimate)

Employer Name and Address (Spouse)

Name of Employer

Work Address (where you go to work)

CityState

Zip Code

Do you have more than one job?*

NoYes
Employer Name and Address (Second Job)

Name of Employer

Work Address (where you go to work)

CityState

Zip Code

Non-Employment Sources of Income

	Your Income	Per Month	Your Spouse	Per Month
Social Security Retirement
Social Security Disability
Social Security for a Minor
Retirement or Pension Income
Unemployment Benefits
Child Support or Alimony
Income generated from business
Rental income
Gratuitous /gift income
Any other income

Debts, Liabilities and Expenses

How much do you owe? Does not have to be exact - best guess is fine for now.

Types of Debt*

	Estimated Amount	Add to bankruptcy*
Credit Cards / Personal Loans
Medical bills
Foreclosures / repossessions
Student Loans
Taxes (federal)
Taxes (state and local)
Mortgages
Automobile Loans
Guarantor / Co-Signors
Other
Other

Have you or your spouse filed bankruptcy before?*

NoYes

Do you have a child support or domestic support obligation?*

NoYes

Current Household Expenses
Please complete this section with as much accuracy as possible, as it will be used to show the Bankruptcy Trustee your current financial situation. When taken into consideration, the total expense amount will dictate, in part, your ability to do either a Chapter 7 or 13. Please state all dollar figures as monthly amounts. The bankruptcy court will not give consideration to luxury expenses or expenditures not deemed necessary. DO NOT INCLUDE payments to credit cards or similar creditors that are subject to stay of collection discharge in bankruptcy.

Estimated amounts are fine for now.

Please list all expenses as monthly figures*

	Monthly Amount	Comment (if needed)
Rent (apartment, lease, trailer
Mortgage payment
Second mortgage or HELOC
Third mortgage or HELOC
Real estate taxes and ins. (if not in mortgage payment)
HOA dues
Electricity average
Natural gas (home) average
Water/Sewer/Gas
Telephone
Cable / Satellite TV / Internet
Home Maintenance ($50 avg. home)
Home Security System
Food and Drink (grocery)
Clothing and cosmetics
Personal care products and services
Childcare / babysitting
Prescriptions / Out-of-Pocket Medical
Health Insurance (not deducted from paycheck)
Dental, eye-care, etc.
Professional dues, memberships
Postage / shipping
Newspaper / Magazine subscriptions
Child support / alimony (not deducted from paycheck)
Life insurance (not deducted from paycheck)
Gym memberships
Cigarettes, vaping, smoking
Pet care / food / medical
Entertainment, gifts
Student loan payments and tuition
Vehicle # 1 payment
Vehicle # 2 payment
Vehicle Insurance
Gasoline (vehicle)
Uber, tolls, parking, bus fees
License plate registration (year divided by 12)
Vehicle repair (estimate)
Ongoing charitable contributions, tithing, gifts
Other
Other
Other

Anything else that you would like us to know about your expenses, such as known or anticipated changes?
For Chapter 7, your Disposable Income must be low to qualify around a hundred dollars or less. For Chapter 13, your Disposable Income is taken into consideration in determining what you would be required to pay in a repayment plan.

	Answer
Physical Street Address
City, State, ZIP
County (i.e. Marion)
Who is on title/deed?
Year Purchased and Price

	Answer
Physical Street Address
City, State, ZIP
Who is on title/deed?
County (i.e. Marion)
Year Purchased and Price

Financial Affairs Inquiry

Information needed in all bankruptcy cases

Answer Yes or No to each question and detail your answer as needed.*

	Answer	Explain your answer here as needed
1. In the last three calendar years, have you received any income other than employment?
2. In the last three calendar years, have you operated any kind of business, sole-proprietorship or trade?
3. In the last 90 days, have you paid more than $600.00 total to any one single creditor?
4. If you operate a business, have you transferred property worth at least $6,000 in the last 90 days?
5. In the last year, have you made any payments to relatives, friends or business partners to pay back a debt?
6. In the last year, ave you been involved in any lawsuit, divorce or administrative proceeding?
7. In the last year, have you had any property, foreclosed, repossessed or money garnished or bank account frozen?
8 In the last year, have you assigned, transferred or sold any property to anyone?
9. In the last year, have you had any losses due to fire, theft, flood, gambly or casualty loss?
10. In the last year, have you spoken to or met with any attorney for any purpose?
11. In the last year, have you made any gifts or charity totalling more than $200 to any individual or organization?
12. In the last year, have you paid anyone for the purpose of debt consolidation, credit counseling or bankruptcy services?
13. Within the last four years, have you sold, gifted, or deeded any property?
14. In the last year, have you closed or transferred any type of financial account?
15. In the last year, have you had access to a safe deposit box, storage unit, or have you stored property at someone's home or place other than your home?
16. Within the last 10 years, have you established any type of trust or estate planning?
17. In the last three years, have you lived at any other address other than your current address?
18. Are you in possession of any property that belongs to someone else? This would include having your name on someone else's bank account, for example.
19. In the last four years, have you been engaged in any type of business as an officer, director or shareholder having more than 5% voting stock?
20. If you own real estate, are you currently in a loan modification or contemplating a loan modification or refinance?

Personal Property and Assets

Federal bankruptcy law requires that you disclose ALL assets and rights to assets, tangible or intangible. Do you have the following:

Answer Yes or No to each question and detail your answer as needed.*

	Answer	Explain your answer here as needed
1. Life Insurance Policy or Annuity
2. Retirement Plan (i.e. 401(k), 403(b), IRA, Roth IRA)
3. Do you anticipate receiving a tax refund?
4. Does anyone owe you more than $500?
5. Do you have cause or reason to sue anyone, for any reason, at this time?
6. Are you the beneficiary of a will or trust?
7. Do you own any stocks or shares?
8. Do you have any copyrights, patents or intellectual property?
9. Do you have any professional license or franchise agreement?
10. Do you have a safe deposit box or storage unit?
11. Do you own any professional mechanics tools or similar equipment?
12. Do you have any inventory, goods or products?
13. Do you own any office or commercial equipment?
14. Do you rent your residence? If so, who is your landlord?
15. Do you have a security deposit with a landlord, utility, etc.? If so, how much?
16. Do you have any pets? What type and how many?
17. Other than a vehicle or house, do you have any single item(s) worth more than $5,000?
18. Do you have any collectibles, including coin collections, etc?
19. Do you rent or lease any personal property, such as furniture or appliances - OR - have you pledged any personal property to secure a loan?

Do you have any type of bank account or pre-paid card?*

YesNo

Personal Property and Assets (continued)

In bankruptcy, there is a certain amount of value that you can keep when it comes to personal property and belongings. For most people who file bankruptcy, the applicable exemptions cover most, if not all property. If you had to sell everything that you own (not including your house or vehicles), how much would you expect to get?
Value of personal proerty?*

CERTIFICATION - READ CAREFULLY

I/We have provided complete and truthful answers to this Bankruptcy Questionnaire and have either completely provided all required information or will supplement my answers to complete same before my case is filed with the court. I/We understand and acknowledge that lying on a bankruptcy petition is a federal crime punishable by a fine of up to $500,000, or imprisonment of up to five (5) years or both. 11 U.S.C. §§ 152 and 3571
Signature (Individual)*

Clear
Signature (spouse)

Clear
Should be Empty:

	Age	Relationship to you	Lives with you?
Dependent 1
Dependent 2
Dependent 3
Dependent 4
Dependent 5
Dependent 6

	District / State	Bankruptcy Chapter	Date/Year Filed (if known)	Status (discharged, dismissed, open)
Prior Bankruptcy Case 1
Prior Bankruptcy Case 2
Prior Bankruptcy Case 3
Prior Bankruptcy Case 4

	Type of Obligation	Recipient's Name (not the child)	Recipient's Address	Current Payment Amount	Past Due Amount (if any)	Court / Jurisdiction
Obligation 1
Obligation 2
Obligation 3
Obligation 4

	Bank Name or Creditor	Monthly Payment	Balance Owing
Primary Mortgage (bank) if applicable
Second Mortgage (bank) if applicable
Tax Liens or Judgment Liens
Purchase-Money Security Interest (i.e. financed windows, hearing and air, etc)
HOA dues

	Bank Name or Creditor	Monthly Payment	Balance Owing
Primary Mortgage (bank) if applicable
Second Mortgage (bank) if applicable
Tax Liens or Judgment Liens
Purchase-Money Security Interest (i.e. financed windows, hearing and air, etc)
HOA dues

	Description	Current Value
Household Goods
Appliances (that you own)
Electronics
Sporting Goods
Hobby Equipment
Tools / Garden
Jewelry
Collectibles
Firearms / weapons
Other
Other
Other

	Answer	Explain your answer here as needed
1. In the last three months, have you used any credit card, taken out any loan or cash advance?
2. Have you ever obtained any credit or loan by means of lying, deception or fraud?
3. Have you ever been accused or convicted of embezzlement or misappropriation of money?
4. Do you expect to receive any money in the foreseeable future that could help you pay your bills and debts?
5. Within the next year, do you expect any significant or substantial change in income?
6. Have you truthfully and fully disclosed ALL of your assets or rights to assets to the best of your knowledge?

	Bank Name	Last Four Digits of Account	Typical or Average Balance
Primary Account
Account
Account
Account
Account
Account

Bankruptcy Questionnaire

Debts, Liabilities and Expenses

Current Household Expenses

Real estate and vehicles

Financial Affairs Inquiry

Personal Property and Assets