Zvi Guttman, Chapter 7 Trustee

Name(s)*

Case No.*

Telephone No.

Please enter a valid phone number.

Home

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Work

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Current Employer Name:*

If none, type none

Current Employer Address

Current Employer Phone Number:

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Email*

example@example.com

Review your Schedules CAREFULLY in connection with your completion of this Questionnaire. If you answer YES to any question please provide details in the Note section below.

0. Did You Personally Review And Then Sign: (A) The Petition, (B) The Schedules, (C) The Statement Of Financial Affairs, (D) The Statement Of Intention (E) The Means Test And All Other Documents Before They Were Filed With The Court?*

YesNo

1. Are all of the following CORRECTLY shown on your Bankruptcy Petition or Schedules:

(a) Address, (b) Social Security Number, (c) Employer and (d) Salary?*

YesNo

1.5. What is your current approximate annual Gross household income $

2. Have you ever filed bankruptcy before?

YesNo

Chapter

Yr. Filed?

Discharge obtained?

YesNo

3a. Have you owned or has your name been on the title or deed to any land, buildings or real estate interests, in the three years preceding the filing of your bankruptcy case? (This includes instances in which your name may appear on a relative's property for convenience or credit purposes.)

YesNo

	Yes	No
3b. If so, have you ever met with or engaged a broker or real estate agent regarding the value, sale or possible sale of such real estate?
3c. Have you or your spouse, child, child's spouse, parent, sibling, grandparent, or grandchild ever claimed said property as exempt in a prior bankruptcy case?
3d. person including a family member even if only for convenience (e.g., your name on a parent's bank account) or has it been during the past one year?

4. List each of your vehicles and provide the following information Check here if more than 4 vehicles

	Year	Make	Model	Insurance with?	Insurance Current?	Vehicle Fully liened &/or Exempt?
A
B
C
D

	Yes	No
5. Have you purchased any vehicle or real estate in the six months prior to the filing of your case?
6. Have you purchased any single item worth more than $3,500 in the past 18 months?
7. Do you serve in the military service of the United States or any of its allies?
8. In the past year have you received, or do you currently anticipate a tax refund (combined State and IRS) of greater than $2,500?
9. Have you placed a security deposit, downpayment or layaway with anyone of more than $2,500?

10. In the six months prior to the filing of your case:

	Yes	No
a. Did you pay or give any one person or company a total of more than $1,000 in money or property?
b. Was any of your money or property seized, surrendered, setoff or garnished?
c. Did you transfer any credit card balances from one card to another via cash advance, telephonic balance transfer or by writing a check on or from a credit account?

11. In the three years prior to the filing of your case, did you do any of the following:

	Yes	No
a. Lend anyone more than $3,000?
b. Repay a loan of more than $3,000 to a friend or family member or business of either?
c. Sell anything worth more than $3,000 whether or not you received at least $3,000 for the item?
d. Give anyone a gift or transfer any money or property having a value of $3000 or more?
e. Rearrange your financial affairs or assets in any way in preparation for filing this bankruptcy (e.g. change tax or retirement withholdings, shift non-exempt assets to exempt, delay or expedite a payment or refund, etc.)?

	Yes	No
12. At the time you filed your case did anyone owe you more than $2,500 (this includes amounts owed by or collectible from an insurance company or by the institution of legal proceedings against another)?
13. Do you own or are you entitled to receive any money or property that is not shown in your Schedules?
14. Are any of your assets NOT listed and/or NOT correctly valued in your Schedules or your Statement of Financial Affairs?
15. In the past year have you received a lump sum distribution of cash or property from any source (e.g. sale or refi of house, liquidation of or loan from retirement asset, lawsuit, inheritance etc.)?
16. Has anybody died from whom you would expect to receive an inheritance or any proceeds of insurance?
17. In the past year, have you met with an attorney, other than your current bankruptcy attorney, for any reason?
18a. In the past four years have you operated or owned any type of business or been self-employed?.
18b. Do you have any interests in any corporations, partnerships, LLP’s and or LLC’s?
19. Do you now or have you had in the past, any interests in offshore accounts (i.e., financial or bank accounts outside the borders of the U.S.) OR own any real estate outside of the United States?
20. Are you the beneficiary or trustee of a trust?
21. Do you believe that you have grounds to file a lawsuit or counter-suit (whether you actually intend or desire to do so) or have you filed a lawsuit or countersuit SEEKING MONETARY DAMAGES (e.g. auto accident, slip & fall, medical malpractice, legal malpractice, worker's compensation, monies owed, etc.)?
22. Do you anticipate the receipt of any income, money or property from any source in the next 12 months other than salary at the scheduled rate (e.g., bonus, raise, commission, inheritance, repayment of loan, divorce decree, settlement, insurance, lawsuit etc.)?
23. Do you have any safe-deposit box or a self-storage unit? (If yes, list all items therein and the location of the box and/or storage unit below or on a separate sheet)

24a. Have you lived in MD continuously for the last 2 years?

YesNo

24b. If not, please list all your address (and move dates) during the last three years.

25. Have you filed all required tax returns for all years prior to this Bankruptcy ?

YesNo

Year of most recent return

26. Have you sold anything online in the 18 months prior to the filing of your case?

YesNo

27. Do you have a personal or business Website or an online Auction or Payment Account (e.g., EBAY, Paypal)?

YesNo

28. Do you own a pre-loaded debit card or gift card?

YesNo

If so, list the approximate value $

29a. Do you own any form of cyber or electronic currency (e.g., bitcoin, Ethereum, Dogecoin)?*

YesNo

b. If, so, do you hold it in a custodial, non-custodial, or hardware wallet?

29c. Do you have, or within the past year had, a cryptocurrency exchange account (e.g., Coinbase, Robinhood, Kraken, CoinEgg, Binance)*

YesNo

29d. Provide name of exchange, broker, etc and high balance w/i past year

30a. Do you have an interest in a retirement account of any type other than social security

YesNo

30b. What type of retirement account is it? (e.g., IRA, 401(k), 403(b), etc)

30c. Is it sponsored or adminstered by your employer?

YesNo

30d. What is its current approximate value?

31a. Are you currently married?

YesNo

31b.What year did you get married?

31c. Have you ever been divorced?

YesNo

32a. If you own a house, is it currently insured?

YesNo

Insurance Company Name

32b. Are premiums current?

YesNo

33c. Do you pay premiums directly or through your mortgage company

33. Who assisted you with the preparation of your most recent tax returns?

If no one, check here

YOU MUST COMPLETELY FILL OUT THIS QUESTIONNAIRE AND SIGN BELOW.

I have completed the aforegoing Questionnaire and have read and understand the Bankruptcy Information Sheet. I swear or affirm under the penalty of perjury that: (a) the answers contained herein are the complete truth, and (b) I have fulfilled or will timely fulfill all of my obligations under 11 U.S.C. §521 and Bankruptcy Rule 4002. I further understand that: (x) the Trustee, the U.S. Trustee and creditors will rely on my answers herein, (y) my continuing obligations to the Trustee, the U.S. Trustee, my creditors and the Court, and (z) I must promptly inform the Trustee if I EVER (i) receive an inheritance relating to a death that took place before or within 6 months after I filed my bankruptcy case or (ii) learn of or assert a claim against anybody, including an insurance company, based in whole or in part upon events that occurred before I filed my bankruptcy case. This is an ongoing obligation that survives the closure of my case. Once completed, please sign electronically.

Signature

Date

NOTES: If your answer requires additional detail or description (i.e., dates, amounts, names, values, etc.) note the question number and the additional details below.