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:
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:
Format: (000) 000-0000.
Cell Phone:
Format: (000) 000-0000.
Work Phone:
Format: (000) 000-0000.
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:
Format: (000) 000-0000.
Cell Phone:
Format: (000) 000-0000.
Work Phone:
Format: (000) 000-0000.
Email Address:

YOUR BUSINESS
Have you owned a business within the past eight (8) years?
- Name of Business:
- EIN:

PREVIOUS BANKRUPTCY FILINGS
Have you filed bankruptcy within the past eight (8) years?
- Case No. 1
- Where Filed:
- Case No:
- Date Filed:
  
  MonthDayYear
- Type:
- Do you have another case to list?
- Case No. 2
- Where Filed:
- Case No:
- Date Filed:
  
  MonthDayYear
- Type:

REAL ESTATE
Do you own or are you buying a home, land or investment property?
- IS THERE A FORECLOSURE NOTICE FOR ANY PROPERTY?

MOBILE HOME
Do you own or are you buying a Mobile Home?
- Mobile Home
- Year:
- Make:
- Model:
- Whose name is on the title?
- Purchase Date:
  
  MonthDayYear
- Value:
- Creditor:
- Amount Owing:
- Monthly Payment:

TIME SHARE
Do you own or are you buying a Time Share?
- Time Share
- Time Share Address:
  
  Street Address
  
  Street Address Line 2
  
  CityState
  
  Zip Code
- Whose name is on the deed?
- Purchase Date:
  
  MonthDayYear
- Value:
- Creditor:
- Amount Owing:
- Monthly Payment:

FURNITURE AND APPLIANCES
Do you have Furniture and Appliances which are paid for:
- Yard Sale Value:
- Do you have Furniture and Appliances which are NOT paid for?
- Item No. 1
- Item:
- Yard Sale Value:
- Creditor:
- Amount Owing:
- Do you have another item to list?
- Item No. 2
- Item:
- Yard Sale Value:
- Creditor:
- Amount Owing:

COLLECTIBLES OF VALUE
Do you have Collectibles of Value such as books, coins, cards, stamps, etc?
- Collectible Item No. 1
- Collectible Item:
- Yard Sale Value:
- Do you have another collectible item to list?
- Collectible Item No. 2
- Collectible Item:
- Yard Sale Value:

EQUIPMENT FOR SPORTS & HOBBIES
Do you have Equipment for Sports or Hobbies?
- Equipment No. 1
- Equipment Item:
- Yard Sale Value:
- Do you have another equipment item to list?
- Equipment No. 2
- Equipment Item:
- Yard Sale Value:

OTHER PERSONAL PROPERTY
Do you have Firearms?
- Firearm Item:
- Yard Sale Value:

ELECTRONICS
Do you have Electronics such as computers, phones, etc?
- Electronic Item No. 1
- Electronic Item:
- Yard Sale Value:
- Do you have another electronic item to list?
- Electronic Item No. 2
- Electronic Item:
- Yard Sale Value:

Do you have Clothes?
- Yard Sale Value:

Do you have Jewelry?
- Yard Sale Value:

Do you have Non-Farm Animals?
- Animal Type:
- Yard Sale Value:

Do you have other Personal Property not already listed?
- Other Personal Property No. 1
- Personal Property Item:
- Yard Sale Value:
- Do you have another personal property item to list?
- Other Personal Property No. 2
- Personal Property Item:
- Yard Sale Value:

FINANCIAL ASSETS
Do you have Cash - Gold or Silver?
- Amount/Value:

Do you have a Checking Account?
- Checking Account No. 1
- Bank Name:
- Amount in Account:
- Do you have another checking account to list?
- Checking Account No. 2
- Bank Name:
- Amount in Account:

Do you have a Savings Account?
- Savings Account No. 1
- Bank Name:
- Amount in Account:
- Do you have another savings account to list?
- Savings Account No. 2
- Bank Name:
- Amount in Account:

Do you have a Certificate of Deposit?
- Bank Name:
- Amount of Certificate:

Do you have other bank accounts not already listed?
- Type of Account:
- Bank Name:
- Amount in Account:

Do you have Bonds, Mutual Funds or Publicly Traded Stocks?
- Institution or Issuer:
- Value:

Do you have Non-publicly Traded Stocks or Interest in Businesses?
- Entity:
- % of Ownership
- Value:

Do you have Government or Corporate Bonds?
- Issuer:
- Value:

Do you have Retirement or Pension Accounts?
- Retirement/Pension Account No. 1
- Type of Account:
- Institution or Issuer:
- Value:
- Do you have another Retirement or Pension Account to list?
- Retirement/Pension Account No. 2
- Type of Account:
- Institution or Issuer:
- Value:

Do you have Security Deposits or Pre-payments?
- Institution:
- Value:

Do you have Annuities?
- Issuer:
- Description:
- Value:

Do you have Education IRA, ABLE Program or State Tuition Program?
- Institution:
- Description:
- Value:

Do you have Trusts or Equitable/Future Interests in Property?
- Description:
- Value:

Do you have Patents, Copyrights, Trademarks or Trade Secrets?
- Description:
- Value:

Do you have Licenses or Franchises?
- Description:
- Value:

MONEY OR PROPERTY OWED TO YOU
Are you expecting an Income Tax Refund?
- Amount:

Does anyone owe you Family Support?
- Amount:

Are there other Amounts Someone Owes You?
- Amount:

Do you have any Insurance Policies with Cash Value?
- Insurer:
- Description:
- Value:

Do you have an Interest in Property Due You from Someone Who Has Died?
- Description:
- Value:

Do you have any Claims Against Third Parties - Lawsuits you have or could file?
- Description:
- Value:

Do you have any Other Contingent or Unliquidated Claims?
- Description:
- Value:

Do you have any Other Financial Assets not already listed?
- Description:
- Value:

BUSINESS RELATED PROPERTY
Do you have Business Related Property?
- Do you have Accounts Receivable?
- Value:

Do you have Office Equipment, Furnishings or Supplies?
- Office Equipment, Furnishings or Supplies No. 1
- Description:
- Value:
- Do you have other Equipment, Furnishings or Supplies to list?
- Office Equipment, Furnishings or Supplies No. 2
- Description:
- Value:

Do you have Machinery, Fixtures, Equipment, Supplies or Tools of Trade?
- Machinery, Fixtures, Equipment or Tools No. 1
- Description:
- Value:
- Do you have other Machinery, Fixtures, Equipment, Supplies or Tools of Trade to list?
- Machinery, Fixtures, Equipment or Tools No. 2
- Description:
- Value:

Do you have Inventory?
- Value:

Do you have any Interest in Partnerships or Joint Ventures?
- Entity:
- % of Ownership
- Value:

Do you have any Customer Lists or Mailing Lists?
- Value:

Do you have any Business-Related Property not already listed?
- Business-Related Property Not Listed No. 1
- Description:
- Value:
- Do you have another Business-Related Property to list?
- Business-Related Property Not Listed No. 2
- Description:
- Value:

FARM AND COMMERCIAL FISHING PROPERTY
Do you have any Farm or Commercial Fishing Property?
- Do you have Farm Animals?
- Value:

Do you have Crops?
- Value:

Do you have Farm or Fishing Equipment?
- Value:

Do you have Farm or Fishing Supplies?
- Value:

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

GENERAL INFORMATION
Have you ever been injured in a car wreck?
- When:

Do you have a claim for damages for anything against anyone?
- What:

Do you owe past due child support?
- To Whom:
- Their Address:
  
  Street Address
  
  Street Address Line 2
  
  CityState
  
  Zip Code
- Amount You Owe:

Do you have any obligations to pay alimony or child support?
- To Whom:
- Their Address:
  
  Street Address
  
  Street Address Line 2
  
  CityState
  
  Zip Code
- Monthly Amount:

Do you owe on a student loan?
- To Whom:
- Amount You Owe:

Do you owe the Internal Revenue Service any money for taxes?
- Tax Years:
- Amount You Owe:

Do you owe any State any money for taxes?
- Tax Years:
- Amount You Owe:

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

Is any vehicle or furniture you have under a lease or lease-to-own?
- Vehicle or Furniture Under Lease No. 1
- Company:
- Item:
- Keep?
- Do you have another vehicle or furniture you have under a lease or lease-to-own to list?
- Vehicle or Furniture Under Lease No. 2
- Company:
- Item:
- Keep?

Are there are any co-signers on any of your debts?
- 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?
- Co-Signer No. 2
- Whom:
- Address
  
  Street Address
  
  Street Address Line 2
  
  CityState
  
  Zip Code
- Which Debt:

EMPLOYMENT INFORMATION - YOU
Your Employment Status:
- 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:
- 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?
- 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?
- 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?
- 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?
- 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?
- Their Name and Address:
- Where:

Did you have income from employment or operation of a business for any part of the last three years?
- Period No. 1 - January 1st Current Year through Present
- Source:
- Amount:
- Period No. 2 - Last Year
- Source:
- Amount:
- Period No. 3 - Two Years Ago
- Source:
- Amount:

Did your Spouse have income from employment or operation of a business for any part of the last three years?
- Period No. 1 - January 1st Current Year through Present
- Source:
- Amount:
- Period No. 2 - Last Year
- Source:
- Amount:
- Period No. 3 - Two Years Ago
- Source:
- Amount:

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)
- Period No. 1 - January 1st Current Year through Present
- Source:
- Amount:
- Period No. 2 - Last Year
- Source:
- Amount:
- Period No. 3 - Two Years Ago
- Source:
- Amount:

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)
- Period No. 1 - January 1st Current Year through Present
- Source:
- Amount:
- Period No. 2 - Last Year
- Source:
- Amount:
- Period No. 3 - Two Years Ago
- Source:
- Amount:

Have you made any payments to creditors totaling more than $600.00 in last 90 days?
- Creditor:
- Date:
  
  MonthDayYear
- Amount Paid:
- Do you have another payment to list?
- Creditor:
- Date:
  
  MonthDayYear
- Amount Paid:

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?
- 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?
- 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?
- Opposing Party:
- Type:
- Court:
- Status:
- Do you have another lawsuit or garnishment to list?
- Opposing Party:
- Type:
- Court:
- Status:

Have you had anything repossessed or foreclosed in the last year?
- Creditor:
- Property:
- When:
- Do you have another repossession or foreclosure to list?
- Creditor:
- Property:
- When:

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?
- Creditor:
- Action:
- Amount:
- Do you have another set off to list?
- Creditor:
- Action:
- Amount:

Have you given any gifts to persons valued over $200.00 within the last 2 years?
- Person:
- Gift:
- Date:
  
  MonthDayYear
- Value:
- Do you have another gift to list?
- Person:
- Gift:
- Date:
  
  MonthDayYear
- Value:

Have you given any gifts to charities totaling over $600.00 within the last 2 years?
- Charity:
- Gift:
- Date:
  
  MonthDayYear
- Value:
- Do you have another gift to list?
- Charity:
- Gift:
- Date:
  
  MonthDayYear
- Value:

Have you had any losses from fire, theft or gambling within the last year?
- Type of Loss:
- Date of Loss:
  
  MonthDayYear
- Amount of Loss:
- If Covered by Insurance, Amount Received:

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?
- Who:
- What:
- Date:
  
  MonthDayYear
- Amount:

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?
- Who:
- What:
- Date:
  
  MonthDayYear
- Amount:

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?
- Who:
- What:
- Date:
  
  MonthDayYear
- Amount:

Have you transferred any property to a self-settled trust or similar device of which you are a beneficiary within the last 10 years?
- Trust:
- What:
- Date:
  
  MonthDayYear
- Amount:

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?
- Institution:
- Type:
- Date:
  
  MonthDayYear
- Amount:
- Do you have another transferred financial account to list?
- Institution:
- Type:
- Date:
  
  MonthDayYear
- Amount:

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?
- Institution:
- Contents:
- Who Else Has Access:
- Do You Still Have It:

Do you hold or control any property that someone else owns (including borrowed, storing or holding in trust)?
- Owner:
- What:
- Where:
- Do you control another property that someone else owns to list?
- Owner:
- What:
- Where:

Have you been notified by any governmental unit that you are or may be liable under or in violation of an environmental law?
- Location:
- Who:
- Law:
- Date:
  
  MonthDayYear

Have you been notified by any governmental unit of any release of hazardous materials?
- Location:
- Who:
- Law:
- Date:
  
  MonthDayYear

Have you been a party in any judicial or administrative proceeding under any environmental law?
- Opposing Party:
- Type:
- Court:
- Status:

Have you owned a business or have any connections to any business within the last 4 years?
- 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?
- Name & Address:
- Date:
  
  MonthDayYear
  Date

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