Comprehensive Bankruptcy Form
To make the most of your Bankruptcy Consultation, please complete this form If you do not know the answer to a question, please leave it blank or provide your best guess.
Basic Information
What is your full name? (First, Middle, Last)
Have you used any other names or aliases in the past 8 years?
YES
NO
What is your phone number?
What is your email address?
example@example.com
Have you filed for bankruptcy in the past 8 years?
YES
NO
Marital Status
Are you legally married, answer, “Yes”, even if separated?
YES
NO
Are you and your spouse, if applicable, separated?
YES
NO
What is your spouse’s full name? (First, Middle, Last) *Please include this information even if separated or if spouse is not filing.
Has your spouse, if your spouse is also filing with you, used any other names or aliases in the past 8 years?
YES
NO
Has your spouse, if your spouse is also filing with you, filed for bankruptcy in the past 8 years?
YES
NO
Do you plan on jointly filing for bankruptcy with your spouse?
YES
NO
If both you and your spouse are jointly filing for bankruptcy, each of you will have to separately complete this Worksheet
Residency
What is your current mailing address?
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Is your mailing address the same as the address where you currently live?
YES
NO
What is the address where you currently live?
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Have you resided in the State of Florida for more than 2 years continuously?
YES
NO
In what state(s) have you resided in within the last two years?
What is your present living circumstance?
Rent
Own/Pay Mortgage
Own/Free & Clear
Other
How long have you lived at your current address?
How much is your monthly rent/mortgage payment each month?
Assets
Do you own any real estate, not counting your residence which you may own or are buying?
YES
NO
What other type(s) of real estate, approximately what is the fair market value, and total amount owed on the real estate?
Do you have a car(s) titled to your name?
YES
NO
Car 1: What is the year/make/model and overall condition of the car- Excellent, Good, Fair, or Poor
How much do you owe on the car?
Do you have any additional cars titled to your name?
YES
NO
Car 2: What is the year/make/model and overall condition of the car- Excellent, Good, Fair, or Poor
How much do you owe on the Car?
Do you have any additional cars titled to your name?
YES
NO
Please list the year/make/model of all other vehicles titled to your name?
Do you have any other types vehicles, motorcycles, campers, trailers, boats, off road vehicles that include you as a registered owner?
YES
NO
What type of other vehicles do you own? Please separate each answer with a comma.
Estimate total value of vehicles other than cars.
Estimate total amount owed on vehicles other than cars.
Do you have any type of retirement plan, for instance, a 401K?
YES
NO
Please provide additional information.
Do you have any right to sue anyone for money?
YES
NO
Please provide additional information.
Do you have any present right to an inheritance?
YES
NO
Please provide additional information.
Specific Asset Questions
Do you own any firearm(s) with a value of over $300?
YES
NO
Do you own any jewelry items with a value of over $300?
YES
NO
Do you own any electronics with a value of over $300?
YES
NO
Do you own any collectibles with a value of over $300?
YES
NO
Do you own any household goods or furniture with a value of over $300?
YES
NO
Do you own any tools to earn income with a value of over $300?
YES
NO
Do you own any hobby equipment or sporting goods with a value of over $300?
YES
NO
Please list all of the items you own worth over $300 as well as a rough estimate of the price the item would sell for at a garage sale.
Liabilities
If you are not sure of the exact amount, please provide your best estimate.
Estimated Total of all Credit Card balances?
Estimated Total of all Medical/Dental balances?
Estimated Total of all Repossession Related Debt?
Estimated Total of all Student Loan Related Debt?
Estimated Total of all Tax Related Debt?
Have any lawsuits been filed against you?
YES
NO
Do any wage garnishments exist against you?
YES
NO
Have you had a repossession in the last year?
YES
NO
Have you paid back money to friends or family in the last two years?
YES
NO
If you answered "YES" to any of the "Liabilities" Questions, please provide additional information.
Income
Who are you presently employed by?
What is your job title?
When did you start this employment?
-
Month
-
Day
Year
date
How much do you receive from wages from this job each month, after taxes?
Do you have a second job?
YES
NO
Job 2: Who is your employer, what is your job title, how long have you been at position, and how much have you received from this job in the past 6 months after taxes?
Have you operated a full or part-time business in the past four years?
YES
NO
How many people, not counting the person or people filing for bankruptcy, are part of your household OVER the age of 18, and are at least partially dependent on you?
How many people, not counting the person or people filing for bankruptcy, are part of your household UNDER the age of 18, and are at least partially dependent on you?
Do any of these dependents contribute money toward paying the household’s expenses in the last 6 months?
YES
NO
What is the total amount of money your dependents have contributed to paying household expenses in the last 6 months?
I
n the past
three years, have you
received any
of the
following
non
-
wage income?
Social Security Benefits (Retirement or Disability)
YES
NO
Total received in past 6 months, if any?
Unemployment
YES
NO
Total received in past 6 months, if any?
Veterans Benefits
YES
NO
Total received in past 6 months, if any?
Retirement Pension (non-Social Security)
YES
NO
Total received in past 6 months, if any?
Public Assistance (Food Stamps etc.)
YES
NO
Total received in past 6 months, if any?
Child Support or Alimony Received
YES
NO
Total received in past 6 months, if any?
Worker’s Comp or Private Disability Benefits
YES
NO
Total received in past 6 months, if any?
Please explain the source and amount of any Non-Wage Related Income you have received in the past 6 months.
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