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:

Have you made any payments to creditors totaling more than $600.00 in last 90 days?*

NoYes - Please provide the following information:

Have you made payments on debts you owe to insiders (anyone other than a creditor - i.e. relatives), including domestic support obligations, in the last year?*

NoYes - Please provide the following information:

Name of Person:
Their Address:

Street Address

Street Address Line 2

CityState

Zip Code
Date Paid:

MonthDayYear
Amount Paid:
Balance Still Owed:

Have you made payments or transferred any property on account of a debt that benefitted an insider (anyone other then a creditor - i.e. relatives) in the last year?*

NoYes - Please provide the following information:

Name of Person:
Their Address:

Street Address

Street Address Line 2

CityState

Zip Code
Date Paid:

MonthDayYear
Amount Paid:
Balance Still Owed:

Have you been a party in any lawsuits and/or garnishments in the last year?*

NoYes - Please provide the following information:

Have you had anything repossessed or foreclosed in the last year?*

NoYes - Please provide the following information:

Have you had a creditor, including a bank or financial institution, set off any amounts from your accounts or refuse to make a payment because you owed a debt in the last 90 days?*

NoYes - Please provide the following information:

Have you given any gifts to persons valued over $200.00 within the last 2 years?*

NoYes - Please provide the following information:

Have you given any gifts to charities totaling over $600.00 within the last 2 years?*

NoYes - Please provide the following information:

Have you had any losses from fire, theft or gambling within the last year?*

NoYes - Please provide the following information:

Have you or anyone on your behalf made any payments or transferred any property to anyone you consulted about seeking bankruptcy or preparing a bankruptcy petition within the last year?*

NoYes - Please provide the following information:

Have you or anyone on your behalf made any payments or transferred any property to anyone who promised to help you deal with your creditors within the last year?*

NoYes - Please provide the following information:

Have you sold, traded, or otherwise transferred any property to anyone other than in the ordinary course of business or financial affairs within the last 2 years?*

NoYes - Please provide the following information:

Have you transferred any property to a self-settled trust or similar device of which you are a beneficiary within the last 10 years?*

NoYes - Please provide the following information:

Have you had any financial accounts or instruments held in your name (checking, savings, money markets, certificates of deposit, etc) closed, sold, moved or transferred within the last year?*

NoYes - Please provide the following information:

Do you have or have had within the last year a safe deposit box or other depository for securities, cash or other valuables, including a storage unit?*

NoYes - Please provide the following information:

Do you hold or control any property that someone else owns (including borrowed, storing or holding in trust)?*

NoYes - Please provide the following information:

Have you been notified by any governmental unit that you are or may be liable under or in violation of an environmental law?*

NoYes - Please provide the following information:

Have you been notified by any governmental unit of any release of hazardous materials?*

NoYes - Please provide the following information:

Have you been a party in any judicial or administrative proceeding under any environmental law?*

NoYes - Please provide the following information:

Have you owned a business or have any connections to any business within the last 4 years?*

NoYes - Please provide the following information:

Name of Business:
EIN:
Address of Business:

Street Address

Street Address Line 2

CityState

Zip Code
Dates in Business: FROM

MonthDayYear
Dates in Business: TO

MonthDayYear
Name of Accountant or Bookkeeper:
Have you given a financial statement to anyone about your business within the last 2 years?

NoYes - Please provide the following information:

You have completed the worksheet.

You may review the worksheet prior to submission by clicking the "Preview PDF" button.

After you are finished reviewing, please click the "Submit" button to email to our office for printing prior to your appointment.
Please verify that you are human*
Should be Empty:

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