New Client Questionnaire

Joint Filer Information

(Must be spouse)
Name*

First NameMiddle NameLast Name
Date of Birth*

MonthDayYear
Date
Social Security #*
Have you used any other names in the past 8 years? *

YesNo
Please list name(s) you have used

First NameMiddle NameLast Name
Please list name(s) you have used

First NameMiddle NameLast Name
Please list name(s) you have used

First NameMiddle NameLast Name
Primary Phone Number*
Please enter a valid phone number.
Email Address*
example@example.com
Have you filed bankruptcy in the past 8 years?*

YesNo
What did you file?
Date of Discharge /Dismissal

MonthDayYear
If date not known, provide an estimate
City & State in which you filed

Street Address

Street Address Line 2

CityState

Zip Code
Case #
Do you pay child support? *

YesNo
Is your child support

Pay to an individualPaycheck withdraw
Who do you pay child support to?

First NameLast Name
Address of person who receives child support

Dependent Information

Please list the dependents you claim on tax returns
Do you have any dependents?*

YesNo
Dependent #1 Relationship
Dependent #1 Age
Dependent #2 Relationship
Dependent #2 Age
Dependent #3 Relationship
Dependent #3 Age
Dependent #4 Relationship
Dependent #4 Age
Dependent #5 Relationship
Dependent #5 Age

2nd Mortgage Information
Who is your second mortgage with?
Bank's Name
Account Number
Lender's Mailing Address
Monthly Payment
Payoff Amount
Loan Interest Rate
How many months are you behind on payments ?
Is property tax included in your payment?

YesNo
Is insurance included in your payment?

YesNo

3rd Mortgage Information
Who is your third mortgage with?
Bank's Name
Account Number
Lender's Mailing Address
Monthly Payment
Payoff Amount
Loan Interest Rate
How many months are you behind on payments ?
Is property tax included in your payment?

YesNo
Is insurance included in your payment?

YesNo

Other Real Estate Property

Rental property, former residence, land, cemetery plots, etc
Property address (If timeshare, please provide company's address)
Current Market Value (PVA)
Are you

Reaffirm the debtSurrender the property
Do you have a mortgage?

YesNo
Who is your mortgage with?
Bank's Name
Account Number
Lender's Mailing Address
Monthly Payment
Payoff Amount
Loan Interest Rate
How many months are you behind on payments ?
Is property tax included in your payment?

YesNo
Is insurance included in your payment?

YesNo

Statement of Financial Affairs
Please list your household income prior to deductions for the following years. Please include ALL income sources including wages, SSI, SSD, retirement, pension, and/or child support.
2025 - Debtor
List all income sources
2025 - Joint Debtor
List all income sources
2024 - Debtor
List all income sources
2024 - Joint Debtor
List all income sources
2023 - Debtor
List all income sources
2023 - Joint Debtor
List all income sources
Has anyone filing paid a total of $600 or more to any one creditor in the last 90 days?*

YesNo
Creditor's Name
If creditor is not listed, please continue to list the creditor information.
Date of Payment

MonthDayYear
Estimate if unsure
Payment Amount
Date of Payment

MonthDayYear
Estimate if unsure
Payment Amount
Date of Payment

MonthDayYear
Estimate if unsure
Payment Amount
Creditor's Name
If creditor is not listed, please continue to list the creditor information.
Date of Payment

MonthDayYear
Estimate if unsure
Payment Amount
Date of Payment

MonthDayYear
Estimate if unsure
Payment Amount
Date of Payment

MonthDayYear
Estimate if unsure
Payment Amount
Creditor's Name
If creditor is not listed, please continue to list the creditor information.
Date of Payment

MonthDayYear
Estimate if unsure
Payment Amount
Date of Payment

MonthDayYear
Estimate if unsure
Payment Amount
Date of Payment

MonthDayYear
Estimate if unsure
Payment Amount
Have you charged, borrowed, or advance money in excess of $600 from one creditor in the past 90 days?*

YesNo
Creditor's Name
If creditor is not listed, please continue to list the creditor information.
Date Acquired

MonthDayYear
Estimate if unsure
Amount Acquired
Purpose of debt
Creditor's Name
If creditor is not listed, please continue to list the creditor information.
Date Acquired

MonthDayYear
Estimate if unsure
Amount Acquired
Purpose of debt
Creditor's Name
If creditor is not listed, please continue to list the creditor information.
Date Acquired

MonthDayYear
Estimate if unsure
Amount Acquired
Purpose of debt
Creditor's Name
If creditor is not listed, please continue to list the creditor information.
Date Acquired

MonthDayYear
Estimate if unsure
Amount Acquired
Purpose of debt

Additional Financial Questions
In the last year, besides Farmer & Wright, have you paid or transfered any property to someone you spoke to about filing bankruptcy?*

YesNo
Please let us know who it was and how much they received
In the last year, did you pay or transfer any property to a person or company who promised to help you deal with your creditors?*

YesNo
Please let us know who it was and how much they received
In the last year, did you sell, trade, or transfer any property to anyone? (Do not list if you have already provided the information on this form.)*

YesNo
Please let us know who it was and how much they received

Business Ownership
Has anyone owned an interest in a business in the past 6 years?*

YesNo
Legal Business Name
Business Address
Employer Identification Number
Type of business:
Business Start Date

MonthDayYear
Estimate if unsure
Business Close Date

MonthDayYear
Leave blank if still operating
Business Equipment, Machinery, & Supplies
List items and dollar value
Business Inventory for Sale
List items and dollar value
All Other Business Property
List items and dollar value
Stock and Ownership Interests in Business
List company's name and value

Household Goods
The trustee requires you to submit the value of your household items. You will not have to sell these items. On the next page, please list the value of the item as if you were selling in a garage sale or online.

If you do not have any of these items, can you please place '0' in the box to acknowledge you do not have any of these items.
This is required by the trustee to file your case. If we do not have this information, your petition would be delayed.

Click to provide your household good values

Household Goods

The trustee requires you to submit the value of your household items. You will not have to sell these items. Please list approximately how many of each you have and the value of the item as if you were selling in a garage sale or online.
Couch(es)
Value in Current Condition
Chair(s)
Value in Current Condition
Lamp(s)
Value in Current Condition
End Tables(s)/Coffee Table(s)
Value in Current Condition
Picture(s)
Value in Current Condition
TV(s), VCR(s), DVD(s), Gaming Systems
Value in Current Condition
Dinette Set(s)
Value in Current Condition
Cabinet(s), Amoire(s), Shelving, etc
Value in Current Condition
1st Bedroom Set
Value in Current Condition
2nd Bedroom Set
Value in Current Condition
3rd Bedroom Set
Value in Current Condition
Dishwasher(s)
Value in Current Condition
Microwave(s)
Value in Current Condition
Stove(s)
Value in Current Condition
Refrigerator(s)
Value in Current Condition
Freezer(s)
Value in Current Condition
Washer(s)
Value in Current Condition
Dryer(s)
Value in Current Condition
Lawnmower(s)
Value in Current Condition
Yard Tools
Value in Current Condition
Home Computer(s)
Value in Current Condition
Kitchen Items - Dishes, Pots & Pans, Small Appliances, etc
Value in Current Condition
Misc. Home Decorations
Value in Current Condition
Misc. Linens - Towels, Sheets, etc
Value in Current Condition
Movies/Video Games/Music
Value in Current Condition
Jewelry (Rings, Watches, Necklaces)
Value in Current Condition

Please list the following value of the following items

List in current condition
Collections (Coins, Stamps, Baseball Cards, etc)
List items and dollar value
Bonds and Notes
List dollar amount and information on bond or note
Farming Equipment/Supplies
List items and dollar value
Farming Animals/Domestic Animals valued above $200
List items and dollar value
Patents, Copyrights, and Franchises
List items and dollar value
Debts People Owe You
List person and amount
Claims You Have Against Other People: (Personal Injury, Worker Compensation, Medical Malpractice claims)
List settlement amount and/or attorney's name
Life Insurance and Annuity Policies:
List name of insurance company, value of the policy, & who's policy it is
Retirement Accounts:
List the provider's name & who's account it is
Any Other Personal Property not listed:
List the items and value

Credit Report Authorization
Farmer & Wright will pull from all three credit report agencies to assist you with your claim.*

I consent to Farmer & Wright, PLLC, to obtain a report of my credit report and use that information from the report to assist with the filing of my case.

Secured/Unsecured Creditor List
On the next few pages, we will ask for creditor information.

Not ALL creditors will appear on your credit report. Creditors such as medical providers, utilities, payday loans, overdrawn checking accounts, and some financial organizations do NOT report the credit bureau. They may not appear until they are turned over to a third-party collector.

If you know you owe a business or someone money, please make sure you provide the information on the next screen.

Please provide the business name ie, Baptist Health vs. medical bills.

Please provide any mailing information you have.

Please provide the most recent known balance.

Prior to filing your case, you will get a chance to review the list of creditors that will be included in your filing.

If your case is filed and a creditor is missing, we might not be able to include that creditor, so please provide as much as you can.
How would you like to get your creditor information to us?*

Click to continue to provide creditor information on this form. If no creditors are provided to us, we will only use the information listed on your credit report.Click to provide us a written list of your creditor information via email at docs@farmerwright.com. If no creditors are provided to us via email, we will only use the information listed on your credit report.I do not want to provide a list of creditors. Please just use my credit report understanding a creditor may be missed, and I might not be able to add it later
What happens if I forget a creditor?*

We might be able to add a creditor for an additional fling fee later. This is not guaranteed. Click to continue and acknowledging this statement.

UNSECURED CREDITORS

List all other creditors including credit cards, personal loans with no collateral, medical bills, past due utilities, overdraft checking, collections, etc.
If a debt has been turned over for collection to an agency or attorney, give the complete name, address, and zip code of the creditor and the complete name, address, and zip code of the collection agency or attorney
Creditor's Name
Creditor's Address
Account Number:
Amount Owed
Please provide at least an estimated amount
Creditor's Name
Creditor's Address
Account Number:
Amount Owed
Please provide at least an estimated amount
Creditor's Name
Creditor's Address
Account Number:
Amount Owed
Please provide at least an estimated amount
Creditor's Name
Creditor's Address
Account Number:
Amount Owed
Please provide at least an estimated amount
Creditor's Name
Creditor's Address
Account Number:
Amount Owed
Please provide at least an estimated amount
Creditor's Name
Creditor's Address
Account Number:
Amount Owed
Please provide at least an estimated amount
Creditor's Name
Creditor's Address
Account Number:
Amount Owed
Please provide at least an estimated amount
Creditor's Name
Creditor's Address
Account Number:
Amount Owed
Please provide at least an estimated amount
Creditor's Name
Creditor's Address
Account Number:
Amount Owed
Please provide at least an estimated amount
Creditor's Name
Creditor's Address
Account Number:
Amount Owed
Please provide at least an estimated amount

Co-Signor Secured/Unsecured Debts

List all debts in which someone co-signed for you or if you co-signed for someone else
Do you have a cosigner or are you a cosigner?*

YesNo
Creditor's Name
Creditor's Address
Co-Signer's Name

First NameLast Name
Co-Signer's Address
Type of Collateral (if any)
If personal property, list known items
Value of Collateral
Creditor's Name
Creditor's Address
Co-Signer's Name

First NameLast Name
Co-Signer's Address
Type of Collateral (if any)
If personal property, list known items
Value of Collateral
Creditor's Name
Creditor's Address
Co-Signer's Name

First NameLast Name
Co-Signer's Address
Type of Collateral (if any)
If personal property, list known items
Value of Collateral
Creditor's Name
Creditor's Address
Co-Signer's Name

First NameLast Name
Co-Signer's Address
Type of Collateral (if any)
If personal property, list known items
Value of Collateral

Past Due Taxes

Please list even if you are or are not paying on them
Do you owe federal taxes? (Individual, Business, Payroll)*

YesNo
Type of Tax
Individual, Business, Payroll
Tax Period
Year of debt
Amount Owed
If unsure, put unsure
Do you owe Kentucky state taxes?*

YesNo
Type of Tax
Individual, Business, Payroll
State
Tax Period
Year of debt
Amount Owed
If unsure, put unsure
Do you owe any other state taxes?*

YesNo
Type of Tax
Individual, Business, Payroll
State
Tax Period
Year of debt
Amount Owed
If unsure, put unsure

Projected Income/Expenses After Filing
The trustee requires us to provide your income and expense AFTER filing bankruptcy.

If you are filing a chapter 13, we use this budget as guidance for your monthly payment.

Please make sure you fill out the income and expenses.

These are the final two pages of the questionnaire.
If we do not provide your income/expenses, your filing would be dismissed.

Click to provide your income and expense

Projected Monthly Income After Filing

The trustee requires you to submit your household budget. Please make sure you list all of your income including your spouse's even if they are not filing.
Debtor's GROSS Earnings
Monthly Income
Spouse's GROSS Earnings
Monthly Income
Debtor's Estimated Overtime
Monthly Income
Spouse's Estimated Overtime
Monthly Income
Debtor's Payroll/Social Security Taxes
Deductions per pay period
Spouse's Payroll/Social Security Taxes
Deductions per pay period
Debtor's Health/Dental/Vision Insurance
Deductions per pay period
Spouse's Health/Dental/Vision Insurance
Deductions per pay period
Debtor's Union Dues
Deductions per pay period
Spouse's Union Dues
Deductions per pay period
Debtor's 401K/Retirement
Deductions per pay period
Spouse's 401K/Retirement
Deductions per pay period
Debtor's Other Payroll Deduction
Deductions per pay period
Spouse's Other Payroll Deductions
Deductions per pay period
Debtor's GROSS Business, Profession, Farm Income
Monthly Income
Spouse's GROSS Business, Profession, Farm Income
Monthly Income
Debtor's GROSS Real Estate Property Income
Monthly Income
Spouse's GROSS Real Estate Property Income
Monthly Income
Debtor's Interest & Dividends Income
Monthly Income
Spouse's Interest & Dividends Income
Monthly Income
Debtor's GROSS Pension or Retirement Income
Monthly Income
Spouse's GROSS Pension or Retirement Income
Monthly Income
Debtor's Alimony or Child Support Received
Monthly Amount
Spouse's Alimony or Child Support Received
Monthly Amount
Debtor's GROSS Social Security
Monthly Amount
Spouse's GROSS Social Security
Monthly Amount
Debtor's Other Monthly Income
Describe and List Amount
Spouse's Other Monthly Income
Describe and List Amount
Debtor's Other Monthly Income
Describe and List Amount
Spouse's Other Monthly Income
Describe and List Amount

Projected Monthly Expenses After Filing

The trustee requires you to submit your household budget. Please make sure you list all of your expenses including expenses you may not be able to pay prior to filing.
Rent/Mortgage/Lot Rent
Electricity/Heating/Gas/Propane
Water/Sewer
Trash Collection
Cell/Home Telephone
Cable/Satellite/On Demand (Netflix, etc)
Internet Service
Home Maintenance
Lawn Care, Pest Control, etc
Groceries
Clothing
Haircuts/Other Grooming
Personal Toiletries
Laundry/Dry Cleaning
Medical/Dental Expenses
Out of Pocket Payments
Transportation
Gasoline, Vehicle Maintenance, Oil Changes
Entertainment/Dining Out/Memberships
Recreation Expenses
Pet Care
Food, Treats, Vet Expenses
Charitable Contributions
Homeowner/Rental Insurance
List if not included with your mortgage payment
Life Insurance
List if not taken out of wages
Auto Insurance
Health Insurance
List if not taken out of wages
Supplemental Insurance
List if not taken out of wages
Property Taxes
List if not included with your mortgage payment
Vehicle Registration Taxes
Make sure you consider all vehicles
Alimony or Child Support Payments
List if not taken out of wages
Auto Installment Payment #1
List if you are reaffirming this debt
Auto Installment Payment #2
List if you are reaffirming this debt
Auto Installment Payment #3
List if you are reaffirming this debt
Business, Professional or Farm Expenses
Other Installment Payment
List payment information
Payment Amount
Other Installment Payment
List payment information
Payment Amount
Other Installment Payment
List payment information
Payment Amount
Other Expense
List payment information
Payment Amount
Other Expense
List payment information
Payment Amount
Other Expense
List payment information
Payment Amount
Should be Empty:

Client Questionnaire

Joint Filer Information

Dependent Information

Mortgage Information

2nd Mortgage Information

3rd Mortgage Information

Other Real Estate Property

Cars, Vans, Trucks, Sports Utility Vehicles, Motorcycles

Boats, Motor Homes, ATV's, Aircraft, Other Recreational Vehicles

Financial Information

Statement of Financial Affairs

Income Information

Income Information

Additional Financial Questions

Additional Financial Questions

Additional Financial Question

Business Ownership

Household Goods

Household Goods

Please list the following value of the following items

Credit Report Authorization

Secured/Unsecured Creditor List

Secured Creditors

UNSECURED CREDITORS

Co-Signor Secured/Unsecured Debts

Past Due Taxes

Projected Income/Expenses After Filing

Projected Monthly Income After Filing

Projected Monthly Expenses After Filing