Bankruptcy Information Worksheet

BANKRUPTCY INFORMATION WORKSHEET
Instructions: Complete all sections to the best of your ability. Mr. Luquire will review all information with you during your consultation.
Date of Appointment:*

MonthDayYear
PERSONAL INFORMATION - YOU
Marital Status:*

Single/Divorced/WidowedMarriedSeparated
Full Name:*

First NameMiddle NameLast NameSuffix
Social Security Number: (optional)
Date of Birth:*

MonthDayYear
Other Names Used: (past 8 years)
Address:*

Street Address

Street Address Line 2

CityState

Zip Code
County:*
Mailing Address: (if different)

Street Address

Street Address Line 2

CityState

Zip Code
Home Phone:
Cell Phone:
Work Phone:
Email Address:

PERSONAL INFORMATION - YOUR SPOUSE
Full Name:

First NameMiddle NameLast NameSuffix
Social Security Number: (optional)
Date of Birth:

MonthDayYear
Other Names Used: (past 8 years)
Address:

Street Address

Street Address Line 2

CityState

Zip Code
County:
Mailing Address: (if different)

Street Address

Street Address Line 2

CityState

Zip Code
Home Phone:
Cell Phone:
Work Phone:
Email Address:

YOUR BUSINESS
Have you owned a business within the past eight (8) years?*

NoYes - Please provide the following information:

PREVIOUS BANKRUPTCY FILINGS
Have you filed bankruptcy within the past eight (8) years?*

NoYes - Please provide the following information:

REAL ESTATE
Do you own or are you buying a home, land or investment property?*

NoYes - Please provide the following information:

MOBILE HOME
Do you own or are you buying a Mobile Home?*

NoYes - Please provide the following information:

TIME SHARE
Do you own or are you buying a Time Share?*

NoYes - Provide the following information:

Time Share
Time Share Address:

Street Address

Street Address Line 2

CityState

Zip Code
Whose name is on the deed?

You OnlyYou & Your SpouseYour Spouse OnlyYou and/or Your Spouse and Another Person
Purchase Date:

MonthDayYear
Value:
Creditor:
Amount Owing:
Monthly Payment:

FURNITURE AND APPLIANCES
Do you have Furniture and Appliances which are paid for:*

NoYes - Please provide the following information:

COLLECTIBLES OF VALUE
Do you have Collectibles of Value such as books, coins, cards, stamps, etc?*

NoYes - Please provide the following information:

EQUIPMENT FOR SPORTS & HOBBIES
Do you have Equipment for Sports or Hobbies?*

NoYes - Please provide the following information:

OTHER PERSONAL PROPERTY
Do you have Firearms?*

NoYes - Please provide the following information:

ELECTRONICS
Do you have Electronics such as computers, phones, etc?*

NoYes - Please provide the following information:

Do you have Clothes?*

NoYes - Please provide the following information:

Do you have Jewelry?*

NoYes - Please provide the following information:

Do you have Non-Farm Animals?*

NoYes - Please provide the following information:

Do you have other Personal Property not already listed?*

NoYes - Please provide the following information:

FINANCIAL ASSETS
Do you have Cash - Gold or Silver?*

NoYes - Please provide the following information:

Do you have a Checking Account?*

NoYes - Please provide the following information:

Do you have a Savings Account?*

NoYes - Please provide the following information:

Do you have a Certificate of Deposit?*

NoYes - Please provide the following information:

Do you have other bank accounts not already listed?*

NoYes - Please provide the following information:

Do you have Bonds, Mutual Funds or Publicly Traded Stocks?*

NoYes - Please provide the following information:

Do you have Non-publicly Traded Stocks or Interest in Businesses?*

NoYes - Please provide the following information:

Do you have Government or Corporate Bonds?*

NoYes - Please provide the following information:

Do you have Retirement or Pension Accounts?*

NoYes - Please provide the following information:

Do you have Security Deposits or Pre-payments?*

NoYes - Please provide the following information:

Do you have Annuities?*

NoYes - Please provide the following information:

Do you have Education IRA, ABLE Program or State Tuition Program?*

NoYes - Please provide the following information:

Do you have Trusts or Equitable/Future Interests in Property?*

NoYes - Please provide the following information:

Do you have Patents, Copyrights, Trademarks or Trade Secrets?*

NoYes - Please provide the following information:

Do you have Licenses or Franchises?*

NoYes - Please provide the following information:

MONEY OR PROPERTY OWED TO YOU
Are you expecting an Income Tax Refund?*

NoYes - Please provide the following information:

Does anyone owe you Family Support?*

NoYes - Please provide the following information:

Are there other Amounts Someone Owes You?*

NoYes - Please provide the following information:

Do you have any Insurance Policies with Cash Value?*

NoYes - Please provide the following information:

Do you have an Interest in Property Due You from Someone Who Has Died?*

NoYes - Please provide the following information:

Do you have any Claims Against Third Parties - Lawsuits you have or could file?*

NoYes - Please provide the following information:

Do you have any Other Contingent or Unliquidated Claims?*

NoYes - Please provide the following information:

Do you have any Other Financial Assets not already listed?*

NoYes - Please provide the following information:

BUSINESS RELATED PROPERTY
Do you have Business Related Property?*

NoYes - Please provide the following information:

Do you have Office Equipment, Furnishings or Supplies?

NoYes - Please provide the following information:

Do you have Machinery, Fixtures, Equipment, Supplies or Tools of Trade?

NoYes - Please provide the following information:

Do you have Inventory?

NoYes - Please provide the following information:

Do you have any Interest in Partnerships or Joint Ventures?

NoYes - Please provide the following information:

Do you have any Customer Lists or Mailing Lists?

NoYes - Please provide the following information:

Do you have any Business-Related Property not already listed?

NoYes - Please provide the following information:

FARM AND COMMERCIAL FISHING PROPERTY
Do you have any Farm or Commercial Fishing Property?*

NoYes - Please provide the following information:

Do you have Crops?

NoYes - Please provide the following information:

Do you have Farm or Fishing Equipment?

NoYes - Please provide the following information:

Do you have Farm or Fishing Supplies?

NoYes - Please provide the following information:

Do you have any Farm/Fishing Related Property not already listed?

NoYes - Please provide the following information:

GENERAL INFORMATION
Have you ever been injured in a car wreck?*

NoYes - Please provide the following information:

Do you have a claim for damages for anything against anyone?*

NoYes - Please provide the following information:

Do you owe past due child support?*

NoYes - Please provide the following information:

Do you have any obligations to pay alimony or child support?*

NoYes - Please provide the following information:

Do you owe on a student loan?*

NoYes - Please provide the following information:

Do you owe the Internal Revenue Service any money for taxes?*

NoYes - Please provide the following information:

Do you owe any State any money for taxes?*

NoYes - Please provide the following information:

Have you filed all of your tax returns for the last 4 years?*

NoYes

Is any vehicle or furniture you have under a lease or lease-to-own?*

NoYes - Please provide the following information:

Are there are any co-signers on any of your debts?*

NoYes - Please provide the following information:

Co-Signer No. 1
Whom:
Their Address:

Street Address

Street Address Line 2

CityState

Zip Code
Which Debt:
Do you have another co-signer on any of your debts to list?

NoYes - Please provide the following information:

Co-Signer No. 2
Whom:
Address

Street Address

Street Address Line 2

CityState

Zip Code
Which Debt:

EMPLOYMENT INFORMATION - YOU
Your Employment Status:*

RetiredDisabledUnemployedEmployed - Please provide the following information:

Employer's Name:
Employer's Address:

Street Address

Street Address Line 2

CityState

Zip Code
Job Position:
Length of Time with Employer:

EMPLOYMENT INFORMATION - YOUR SPOUSE
Your Spouse's Employment Status:

RetiredDisabledUnemployedEmployed - Please provide the following information:

Your Spouse's Employer's Name:
Your Spouse's Employer's Address:

Street Address

Street Address Line 2

CityState

Zip Code
Your Spouse's Job Position:
Your Spouse's Length of Time with Employer:

MONTHLY INCOME FROM EMPLOYMENT - YOU
Gross Income:
Deductions:
Taxes:
Retirement - Mandatory:
Retirement - Voluntary:
Retirement Fund Loan Repayment:
Insurance:
Domestic Support Obligations:
Union Dues:
Other Deduction Type:
Amount:
Other Deduction Type:
Amount:
Net Monthly Income:

MONTHLY INCOME FROM OTHER SOURCES - YOU
Social Security:
Retirement:
Child Support:
Business Income:
Food Stamps:
Other Income Type:
Amount:
Other Income Type:
Amount:
Other Income Type:
Amount:
Total Monthly Income From Other Sources:
Total Monthly Income:
Variations in Income in next 12 months

MONTHLY INCOME FROM EMPLOYMENT - YOUR SPOUSE
Gross Income:
Deductions:
Taxes:
Retirement - Mandatory:
Retirement - Voluntary:
Retirement Fund Loan Repayment:
Insurance:
Domestic Support Obligations:
Union Dues:
Other Deduction Type:
Amount:
Other Deduction Type:
Amount:
Net Income:

MONTHLY INCOME FROM OTHER SOURCES - YOUR SPOUSE
Social Security:
Retirement:
Child Support:
Business Income:
Food Stamps:
Other Income Type:
Amount:
Other Income Type:
Amount:
Other Income Type:
Amount:
Total Monthly Income From Other Sources:

What is the total number of people who regularly live in your household including yourself?*

MONTHLY LIVING EXPENSES
The rental or home ownership expenses for your residence: (include first mortgage payments and any rent for the ground or lot)
If not included above:
Real estate taxes:
Property, homeowner's or renter's insurance:
Home maintenance, repair, and upkeep:
Homeowner's association or condominium dues:
Additional mortgage payments for your residence: (such as home equity loans)
Utilities:
Electricity, heat, natural gas:
Water, sewer, garbage collection:
Telephone, cell phone, Internet, satellite, and cable services:
Other - Specify:
Amount:
Food and housekeeping supplies:
Childcare and children's education costs:
Clothing, laundry, and dry cleaning:
Personal care products and services:
Medical and dental expenses:
Transportation: (include gas, maintenance, bus or train fare. do not include car payments):
Entertainment, clubs, recreation, newspapers, magazines, and books:
Charitable contributions and religious donations:
Insurance (Do not include insurance deducted from your pay or property or homeowner's insurance.):
Life insurance:
Vehicle insurance:
Health insurance:
Other insurance - Specify:
Amount:
Taxes - Specify: (do not include taxes deducted from your pay or property or homeowner's taxes)
Amount:
Installment or Lease Payments:
Car payment for Vehicle 1:
Car payment for Vehicle 2:
Other - Specify:
Amount:
Other - Specify:
Amount:
Your payments of alimony, maintenance, and support that you did not report as deducted from your pay:
Other payments you make to support others who do not live with you - Specify:
Amount:
Other real property expenses not included in line 1:
Mortgage on other property:
Real estate taxes:
Property, homeowner's, or renter's insurance:
Maintenance, repair, and upkeep expenses:
Homeowner's association or condominium dues:
Other - Specify:
Amount:
Total Expenses:
Variations in Expenses in next 12 months

STATEMENT OF FINANCIAL AFFAIRS
Have you lived at any other address other than your current address in the last 3 years?*

NoYes - Please provide the following information:

Previous Address No. 1
Previous Address:

Street Address

Street Address Line 2

CityState

Zip Code
Dates you lived there?
Do you have another previous address to list?

NoYes - Please provide the following information:

Previous Address No. 2
Previous Address:

Street Address

Street Address Line 2

CityState

Zip Code
Dates you lived there?

Has your Spouse lived at any other address other than their current address in the last 3 years?

NoYes - Please provide the following information:

Spouse's Previous Address No. 1
Spouse's Previous Address:

Street Address

Street Address Line 2

CityState

Zip Code
Dates your Spouse lived there?
Do you have another previous address for your Spouse to list?

NoYes - Please provide the following information:

Spouse's Previous Address No. 2
Spouse's Previous Address:

Street Address

Street Address Line 2

CityState

Zip Code
Dates your Spouse lived there?

Have you resided in a community property state (Arizona, California, Idaho, Louisiana, Nevada, New Mexico, Puerto-Rico, Texas, Washington or Wisconsin) in the last 8 years?*

NoYes - Please provide the following information about your spouse or ex-spouse who resided in that state with you?

Did you have income from employment or operation of a business for any part of the last three years?*

NoYes - For each period indicated, please provide your gross income before any deductions or exclusions:

Did your Spouse have income from employment or operation of a business for any part of the last three years?

NoYes - For each period indicated, please provide your Spouse's gross income before any deductions or exclusions:

Did you have income from other sources other than employment for any period during the past three years? (i.e. retirement, social security, SSI, child support)*

NoYes - For each period indicated, please provide your gross other income before any deductions or exclusions:

Did your Spouse have income from other sources other than employment for any period during the past three years? (i.e. retirement, social security, SSI, child support)

NoYes - For each period indicated, please provide your Spouse's gross other income before any deductions or exclusions:

BANKRUPTCY INFORMATION WORKSHEET

PERSONAL INFORMATION - YOU

PERSONAL INFORMATION - YOUR SPOUSE

YOUR BUSINESS

PREVIOUS BANKRUPTCY FILINGS

REAL ESTATE

MOBILE HOME

TIME SHARE

VEHICLES/SUVs/MOTORCYCLES/TRACTORS

WATERCRAFT, AIRCRAFT, MOTOR HOMES, ATVS AND OTHER RECREATIONAL VEHICLES

FURNITURE AND APPLIANCES

COLLECTIBLES OF VALUE

EQUIPMENT FOR SPORTS & HOBBIES

OTHER PERSONAL PROPERTY

ELECTRONICS

FINANCIAL ASSETS

MONEY OR PROPERTY OWED TO YOU

BUSINESS RELATED PROPERTY

FARM AND COMMERCIAL FISHING PROPERTY

GENERAL INFORMATION

EMPLOYMENT INFORMATION - YOU

EMPLOYMENT INFORMATION - YOUR SPOUSE

MONTHLY INCOME FROM EMPLOYMENT - YOU

MONTHLY INCOME FROM OTHER SOURCES - YOU

MONTHLY INCOME FROM EMPLOYMENT - YOUR SPOUSE

MONTHLY INCOME FROM OTHER SOURCES - YOUR SPOUSE

DEPENDENT INFORMATION

MONTHLY LIVING EXPENSES

STATEMENT OF FINANCIAL AFFAIRS