William Casey Bankruptcy Questionnaire

IMPORTANT QUESTIONS
Are you in danger of REPOSSESSION?
How many months behind?
Are you in danger of FORECLOSURE?
How many months behind?
Are you in danger of a GARNISHMENT?
Are you being SUED or are you going through a DIVORCE?
Do you have CHILD SUPPORT ARREARAGE?
Are you receiving a TAX REFUND?
Have you TRANSFERRED PROPERTY to someone in the past 2 Years?
Have you taken a CASH ADVANCE from a Credit Cardin the past 90 days?
Have you been involved in an AUTO WRECK, CLASS ACTION SUIT, OR MASS TORT CASE in the last two Years?
10 Have you repaid over 500.00 to family members in the last year?
11 Do you owe any back taxes
Have you filed past two years Tax Returns?
GENERAL INFORMATION
MARITIAL STATUS:
Marital Status:

MarriedSeparatedDivorcedSingleWidowed
CHAPTER 7 BANKRUPTCY
CHAPTER 13 BANKRUPTCY
Filing:

JointSingle
NOTE: IF FILING SINGLE AND YOU ARE MARRIED, THERE IS NO NEED TO LIST SPOUSE INFORMATION.
FIRST*
FULL MIDDLE*
LAST*
DATE OF BIRTH*

MonthDayYear
Date
OTHER NAMES THAT YOU HAVE USED PREVIOUS MARRIED OR MAIDEN NAMES
HAVE YOU LIVED IN THE STATE OF ALABAMA FOR THE LAST 6 MONTHS?

YesNo
ADDRESS CITY STATE AND ZIP CODE
COUNTY
PRIOR ADDRESS USED: (IN THE PAST THREE YEARS)
ADDRESS
DATES LIVED THERE

MonthDayYear
Date
ADDRESS
DATES LIVED THERE

MonthDayYear
Date
TELEPHONE NUMBERS: HOME:
HOME
WORK
CELL
OTHER
EMAIL ADDRESS*
example@example.com
SPOUSE INFORMATION: (IF FILING JOINT)
FIRST
FULL MIDDLE
LAST
DATE OF BIRTH

MonthDayYear
Date
EMAIL ADDRESS
example@example.com
OTHER NAMES THAT SPOUSE HAS USED PREVIOUS MARRIED OR MAIDEN NAMES
NAMES AND AGES OF CHILDRE LIVING WITH YOU:
FULL NAME
AGE
SON OR DAUGHTER
EMPLOYED
FULL NAME
AGE
SON OR DAUGHTER
EMPLOYED
FULL NAME
AGE
SON OR DAUGHTER
EMPLOYED
FULL NAME
AGE
SON OR DAUGHTER
EMPLOYED
FULL NAME
AGE
SON OR DAUGHTER
EMPLOYED
FULL NAME
AGE
SON OR DAUGHTER
EMPLOYED
HAVE YOU EVER FILED A BANKRUPTCY BEFORE?

YesNo
IF CHECKED YES PLEASE PROVIDE THE FOLLOWING INFORMATION:
DATE FILED

MonthDayYear
Date
STATE CITY AND COUNTY FILED IN
CASE NUMBER
CHAPTER 7
OR CHAPTER 13
DATE DISCHARGED

MonthDayYear
Date
PROPERTY QUESTIONS

PLEASE GIVE THE VALUE OF EACH PROPERTY AND BRIEF DESCRIPTION
1. REAL PROPERTY (HOUSE, LAND, BUILDINGS, CONDOMINIUMS, MOBILE HOME) (LIST WHERE LOCATED ALSO)
YEAR, MAKE, MODEL, SIZE OF MOBILE HOME
2 CASH ON HAND
3 CHECKING ACCOUNT PLEASE LIST NAME OF BANK AND AMOUNT IN ACCOUNT
4 SAVINGS ACCOUNT PLEASE LIST NAME OF BANK AND AMOUNT IN ACCOUNT
5 SECURITY DEPOSITS
6 HOUSEHOLD GOODS AND FURNISHINGS INCLUDE AUDIO VIDEO AND COMPUTER EQUIPMENT PLEASE LIST EACH ITEM SEPARETLY AND GIVE THEM A YARD SALE VALUE
7. BOOKS PICTURES AND OTHER ART OBJECTS
8 WEARING APPAREL
9 FURS AND JEWELERY
12 ANNUITIES
11 INTEREST IN INSURANCE POLICIES
10 FIREARMS AND SPORTS HOBBY EQUIPMENT
13. INTEREST IN IRA OR OTHER PENSION OF PROFIT SHARING PLANS
14 STOCK AND INTEREST IN BUSINESSES
15 INTEREST IN PARTERSHIPS OR JOINT VENTURES
16 GOVERNMENT AND CORPORATE BONDS
17 ACCOUNTS RECEIVABLE
18. ALIMONY, MAINTENANCE, SUPPORT AND PROPERTY SETTLEMENTS IN WHICH THEDEPTOR MAY BE ENTITLED
19. OTHER LIQUIDATED DEPTS OWING DEPTOR INCLUDING TAX REFUND
20. EQUITABLE OR FUTURE INTEREST, LIFE ESTATES AND RIGHTS OR POWERSEXERCISABLE FOR THE BENEFIT OF THE DEBTOR OTHER THAN LISTED IN SCHEDULEOF REAL PROPERT
21 CONTINGENT AND NONCONTINGENT INTERESTS IN ESTATE OF A DECENDENT DEATH BENEFIT PLAN LIFE INSURANCE POLICY OR TRUST
22 OTHER CONTINGENT AND UNLIQUIDATED CLAIMS OF EVERY NATURE

MonthDayYear
Date
23. PATENTS, COPYRIGHTS AND OTHER INTELLECTUAL PROPERTY
24 LICENSES FRANCHISES AND OTHER GENERAL INTANGIBLES
25. AUTOMOBILES, TRUCKS, TRAILERS AND OTHER VEHICLES AND ACCESSORIES (LIST THE YEAR, MAKE, MODEL AND TRIM OF VEHICLE ALSO CONDITION OF VEHICLE AND HOW MANY MILES ON VEHICLE)
VEHICLE 1
VEHICLE 2
VEHICLE 3
VEHICLE 4
VEHICLE 5
VEHICLE 6
26 BOATS MOTORS AND ACCESSORIESNEED YEAR MAKE AND MODEL
27 AIRCRAFT AND ACCESSORIES
28. OFFICE EQUIPMENT, FURNISHINGS AND SUPPLES
29 MACHINERY FIXTURES EQUIPMENT AND SUPPLIES USED IN BUSINESS
30 INVENTORY
31 ANIMALS
32 CROPSGROWING OR HARVESTED
33 FARMING EQUIPMENT AND IMPLEMENTS
34 FARM SUPPLIES CHEMICALS AND FEED
35 OTHER PERSONAL PROPERTY OF ANY KIND NOT ALREADY LISTED
CREDITORS HOLDING SECURED CLAIMS SUCH AS MORTGAGES, CAR LOANS, FURNITURE LOANS & TAX LIENS

NOTE: PLEASE LIST CREDITORS FULL ADDRESS INCLUDING CITY, STATE AND ZIP CODE. ALSO PLEASE LIST THE DATE THAT YOU INCURRED THIS DEBT AND IF YOU WOULD LIKE
CREDITOR'S NAME: CREDITOR'S ADDRESS:
CREDITORS NAME
CREDITORS ADDRESS
ACCOUNT NUMBER
JOINT ACCOUNT OR SINGLE ACCOUNT
DATE CLAIM WAS INCURRED

MonthDayYear
Date
NATURE OF LIEN AND DESCRIPTION AND MARKET VALUE OF PROPERTY SUBJECT TO LIEN
AMOUNT OF CLAIM
MONTHLY NOTE ON CLAIM
DO YOU WISH TO KEEP THIS CLAIM
CREDITORS NAME
CREDITORS ADDRESS
ACCOUNT NUMBER
JOINT ACCOUNT OR SINGLE ACCOUNT
DATE CLAIM WAS INCURRED

MonthDayYear
Date
NATURE OF LIEN AND DESCRIPTION AND MARKET VALUE OF PROPERTY SUBJECT TO LIEN
AMOUNT OF CLAIM
MONTHLY NOTE ON CLAIM
DO YOU WISH TO KEEP THIS CLAIM
CREDITORS NAME
CREDITORS ADDRESS
ACCOUNT NUMBER
DATE CLAIM WAS INCURRED

MonthDayYear
Date
JOINT ACCOUNT OR SINGLE ACCOUNT
NATURE OF LIEN AND DESCRIPTION AND MARKET VALUE OF PROPERTY SUBJECT TO LIEN
AMOUNT OF CLAIM
MONTHLY NOTE ON CLAIM
DO YOU WISH TO KEEP THIS CLAIM
CREDITORS NAME
CREDITORS ADDRESS
ACCOUNT NUMBER
JOINT ACCOUNT OR SINGLE ACCOUNT
DATE CLAIM WAS INCURRED

MonthDayYear
Date
NATURE OF LIEN AND DESCRIPTION AND MARKET VALUE OF PROPERTY SUBJECT TO LIEN
AMOUNT OF CLAIM
MONTHLY NOTE ON CLAIM
DO YOU WISH TO KEEP THIS CLAIM
CREDITORS NAME
CREDITORS ADDRESS
ACCOUNT NUMBER
DATE CLAIM WAS INCURRED

MonthDayYear
Date
JOINT ACCOUNT OR SINGLE ACCOUNT
NATURE OF LIEN AND DESCRIPTION AND MARKET VALUE OF PROPERTY SUBJECT TO LIEN
AMOUNT OF CLAIM
MONTHLY NOTE ON CLAIM
DO YOU WISH TO KEEP THIS CLAIM
CREDITORS NAME
CREDITORS ADDRESS
ACCOUNT NUMBER
DATE CLAIM WAS INCURRED

MonthDayYear
Date
JOINT ACCOUNT OR SINGLE ACCOUNT
NATURE OF LIEN AND DESCRIPTION AND MARKET VALUE OF PROPERTY SUBJECT TO LIEN
AMOUNT OF CLAIM
MONTHLY NOTE ON CLAIM
DO YOU WISH TO KEEP THIS CLAIM
CREDITORS NAME
CREDITORS ADDRESS
ACCOUNT NUMBER
JOINT ACCOUNT OR SINGLE ACCOUNT
DATE CLAIM WAS INCURRED

MonthDayYear
Date
NATURE OF LIEN AND DESCRIPTION AND MARKET VALUE OF PROPERTY SUBJECT TO LIEN
AMOUNT OF CLAIM
MONTHLY NOTE ON CLAIM
DO YOU WISH TO KEEP THIS CLAIM
CREDITORS NAME
CREDITORS ADDRESS
ACCOUNT NUMBER
DATE CLAIM WAS INCURRED

MonthDayYear
Date
JOINT ACCOUNT OR SINGLE ACCOUNT
NATURE OF LIEN AND DESCRIPTION AND MARKET VALUE OF PROPERTY SUBJECT TO LIEN
AMOUNT OF CLAIM
MONTHLY NOTE ON CLAIM
DO YOU WISH TO KEEP THIS CLAIM
CREDITORS NAME
CREDITORS ADDRESS
ACCOUNT NUMBER
JOINT ACCOUNT OR SINGLE ACCOUNT
DATE CLAIM WAS INCURRED

MonthDayYear
Date
NATURE OF LIEN AND DESCRIPTION AND MARKET VALUE OF PROPERTY SUBJECT TO LIEN
AMOUNT OF CLAIM
MONTHLY NOTE ON CLAIM
DO YOU WISH TO KEEP THIS CLAIM
CREDITORS HOLDING UNSECURED NONPRIORITY CLAIMS

NOTE: PLEASE LIST CREDITORS FULL ADDRESS INCLUDING CITY, STATE AND ZIP CODE. ALSO PLEASE LIST THE DATE THAT YOU INCURRED THIS DEBT AND IF YOU WOULD LIKE TO KEEP IT OR NOT.
CREDITORS NAME
CREDITORS ADDRESS
ACCOUNT NUMBER
SINGLE ACCOUNT OR JOINT ACCOUNT
DATE CLAIM WAS INCURRED

MonthDayYear
Date
AMOUNT OF CLAIM
TYPE OF CLAIM OR ACCOUNT
DO YOU WISH TO KEEP THIS CLAIM
CREDITORS NAME
CREDITORS ADDRESS
ACCOUNT NUMBER
DATE CLAIM WAS INCURRED

MonthDayYear
Date
SINGLE ACCOUNT OR JOINT ACCOUNT
AMOUNT OF CLAIM
TYPE OF CLAIM OR ACCOUNT
DO YOU WISH TO KEEP THIS CLAIM
CREDITORS NAME
CREDITORS ADDRESS
ACCOUNT NUMBER
SINGLE ACCOUNT OR JOINT ACCOUNT
DATE CLAIM WAS INCURRED

MonthDayYear
Date
AMOUNT OF CLAIM
TYPE OF CLAIM OR ACCOUNT
DO YOU WISH TO KEEP THIS CLAIM
CREDITORS NAME
CREDITORS ADDRESS
ACCOUNT NUMBER
DATE CLAIM WAS INCURRED

MonthDayYear
Date
SINGLE ACCOUNT OR JOINT ACCOUNT
AMOUNT OF CLAIM
TYPE OF CLAIM OR ACCOUNT
DO YOU WISH TO KEEP THIS CLAIM
CREDITORS NAME
CREDITORS ADDRESS
ACCOUNT NUMBER
DATE CLAIM WAS INCURRED

MonthDayYear
Date
SINGLE ACCOUNT OR JOINT ACCOUNT
AMOUNT OF CLAIM
TYPE OF CLAIM OR ACCOUNT
DO YOU WISH TO KEEP THIS CLAIM
CREDITORS NAME
CREDITORS ADDRESS
ACCOUNT NUMBER
SINGLE ACCOUNT OR JOINT ACCOUNT
DATE CLAIM WAS INCURRED

MonthDayYear
Date
AMOUNT OF CLAIM
TYPE OF CLAIM OR ACCOUNT
DO YOU WISH TO KEEP THIS CLAIM
CREDITORS NAME
CREDITORS ADDRESS
ACCOUNT NUMBER
DATE CLAIM WAS INCURRED

MonthDayYear
Date
SINGLE ACCOUNT OR JOINT ACCOUNT
AMOUNT OF CLAIM
TYPE OF CLAIM OR ACCOUNT
DO YOU WISH TO KEEP THIS CLAIM
CREDITORS NAME
CREDITORS ADDRESS
ACCOUNT NUMBER
DATE CLAIM WAS INCURRED

MonthDayYear
Date
SINGLE ACCOUNT OR JOINT ACCOUNT
AMOUNT OF CLAIM
TYPE OF CLAIM OR ACCOUNT
DO YOU WISH TO KEEP THIS CLAIM
CREDITORS NAME
CREDITORS ADDRESS
ACCOUNT NUMBER
DATE CLAIM WAS INCURRED

MonthDayYear
Date
SINGLE ACCOUNT OR JOINT ACCOUNT
TYPE OF CLAIM OR ACCOUNT
AMOUNT OF CLAIM
DO YOU WISH TO KEEP THIS CLAIM
CREDITORS NAME
CREDITORS ADDRESS
ACCOUNT NUMBER
SINGLE ACCOUNT OR JOINT ACCOUNT
DATE CLAIM WAS INCURRED

MonthDayYear
Date
AMOUNT OF CLAIM
TYPE OF CLAIM OR ACCOUNT
AMOUNT OF CLAIM DO YOU WISH TO KEEP THIS CLAIM
DO YOU WISH TO KEEP THIS CLAIM
CREDITORS NAME
CREDITORS ADDRESS
ACCOUNT NUMBER
DATE CLAIM WAS INCURRED

MonthDayYear
Date
SINGLE ACCOUNT OR JOINT ACCOUNT
AMOUNT OF CLAIM
TYPE OF CLAIM OR ACCOUNT
DO YOU WISH TO KEEP THIS CLAIM
CREDITORS NAME
CREDITORS ADDRESS
ACCOUNT NUMBER
DATE CLAIM WAS INCURRED

MonthDayYear
Date
SINGLE ACCOUNT OR JOINT ACCOUNT
AMOUNT OF CLAIM
TYPE OF CLAIM OR ACCOUNT
DO YOU WISH TO KEEP THIS CLAIM
CURRENT INCOME OF INDIVIDUAL DEBTOR(S): DEBTOR 1
NAME OF EMPLOYER
OCCUPATION
LENGTH OF EMPLOYMENT
PAY PERIOD

WeeklyBiweeklyMonthly
GROSS INCOME
FEDERAL TAXES WITHELD
STATE TAXES WITHELD
MEDICARE TAXES WITHELD
SOCIAL SECURITY TAXES WITHELD
INSURANCE
UNION DUES
RETIREMENT
OTHER
DEBTOR 2 OR NON FILING SPOUSE
NAME OF EMPLOYER
OCCUPATION
LENGTH OF EMPLOYMENT
PAY PERIOD:

WeeklyBiweeklyMonthly
GROSS INCOME
FEDERAL TAXES WITHHELD
STATE TAXES WITHHELD
MEDICARE TAXES WITHHELD
SOCIAL SECURITY TAXES WITHHELD
INSURANCE
UNION DUES
RETIREMENT
OTHER
DO YOU OR YOUR SPOUSE RECEIVE OR HAVE RECEIVED IN THE PAST TWO YEARS ANY OTHER TYPE INCOME? (SOCIAL SECURITY, UNEMPLOYMENT, WORKMAN'S COMP, ETC.)

IF YES, PLEASE GIVE FOLLOWING INFORMATION: TYPE OF INCOME
TYPE OF INCOME
DEBTOR OR SPOUSE
MONTH/YEAR STARTED RECEIVING
MONTH/YEAR STOPPED RECEIVING
MONTHLY PAYMENT RECEIVED
PLEASE PROVIDE THE FOLLOWING INFORMATION: AMOUNT OF GROSS INCOME FROM EMPLOYMENT FOR THE LAST TWO YEARS INCLUDING WHAT YOU HAVE MADE YEAR TO DATE.
YOU
SPOUSE
2018
2019
2020 THRU NOW
DEBTOR 1
Other Income
Social Security
Retirement
Food Stamps
Unemployment
Child Support
Alimony
VA Benefits
Other
DEBTOR 2 / NON FILING SPOUSE
Other Income
Social Security
Retirement
Food Stamps
Unemployment
Child Support
Alimony
VA Benefits
Other
CURRENT MONTHLY EXPENSES
MORTGAGE NOTE
RENT NOTE
ELECTRICITY
GAS
WATER
TELEPHONE
CABLE TELEVISION
GARBAGE SERVICE
GROCERIES
CLOTHING
LAUNDRY / DRY CLEANING
DOCTOR
PRESCRIPTIONS
GASOLINE / TRANSPORTATION
CAR NOTE(S)
CAR LEASE NOTE
HOUSE RENTER'S INSURANCE
AUTOMOBIL INSURANCE
HEALTH INSURANCE (IF NOT DEDUCTED FROM PAYCHECK)
ANY OTHER EXPENSES: such as child care, tuition, college expenses, lot rent, tithes, cancer/life insurance, etc.
MONTHLY NOTE
DO YOU HAVE ANY GARNISHMENTS AGAINST YOU? IF YES, PLEASE LIST THE FOLLOWING:
WHO IS GARNISHING YOUR WAGES
ADDRESS OF WHO IS GARISHING YOUR WAGES
CASE NUMBER
DATE GARNISHMENT WAS ISSUED

MonthDayYear
Date
WHAT TYPE OF DEBT IS THIS
HOW MUCH ARE THEY GARNISHING FOR?
HOW MUCH HAVE THEY GARNISHED?
PLEASE LIST THIS DEBT UNDER YOUR UNSECURED DEBTS. (ALSO IF YOU HAVE THE DOCUMENTS FOR THE GARNISHMENT WE WOULD LIKE TO MAKE COPIES OF THEM)
CHILD SUPPORT: PLEASE INDICATE ANY AND ALL PERSONS TO WHOM YOU OWE CHILD SUPPORT (PARENT'S NAME) ALSO GIVE CASE NUMBER IF YOU HAVE ONE AND AMOUNT YOU ARE BEHIND, IF YOU ARE BEHIND (ARREARAGE).
1 PARENTS NAME AND ADDRESS
NAME OF CHILD
MONTHLY PAYMENT AMOUNT
ARREARAGE AMOUNT
STATE AGENCY THAT ISSUED CHILD SUPPORT
2 PARENTS NAME AND ADDRESS
NAME OF CHILD
MONTHLY PAYMENT AMOUNT
ARREARAGE AMOUNT
STATE AGENCY THAT ISSUED CHILD SUPPORT
QUESTIONS FOR STATEMENT \ OF FINANCIAL AFFAIRS (MUST BE ANSWERED)
PLEASE ANSWER THESE QUESTIONS AND PROVIDE ALL INFORMATION THAT IS REQUESTED.

1. HAVE YOU HAD ANY REPOSSESSION OR RETURNED ANY PROPERTY TO ANY CREDITORS IN THE LAST YEAR? IF YES, PLEASE PROVIDE THE FOLLOWING:
DATE OF RETURN

MonthDayYear
Date
DESCRIPTION OF MERCHANDISE RETURNED:
VALUE OF MERCHANDISE RETURNED:
CREDITORS NAME
CREDITOR'S ADDRESS
2. HAVE YOU TRANSFERRED, GIVEN, SOLD OR DISPOSED OF ANYTHING (HOUSE, LAND, CAR, FURNITURE, JEWELERY, ETC) IN THE LAST YEAR? IF YES, PLEASE PROVIDE THE FOLLOWING:
WHEN SOLD / TRANSFERRED
WHAT WAS SOLD / TRANSFFERED
AMOUNT RECEIVED
WHAT WERE FUNDS USED FOR?
3. HAVE ANY LAWSUITS BEEN FILED AGAINST YOU OR HAVE ANY JUDGEMENTS BEEN ENTERED AGAINST YOU? IF YES, PLEASE PROVIDE THE FOLLOWING INFORMATION:
NAME OF PLAINTIFF
COURT LOCATIONS COUNTY AND STATE
CASE NUMBER
STATUS OF CASE PENDING OR JUDGEMENT
4. HAVE YOU FILED ANY LAWSUITS AGAINST ANYONE OR ARE YOU EXPECTING TO RECEIVE ANY SETTLEMENT FOR ANY CLAIMS (INSURANCE CLAIMS, CAR WRECKS, ETC.) IF YES PLEASE, EXPLAIN:
EXPLANATION
5. HAVE YOU CLOSED ANY BANK ACCOUNTS WITHIN THE LAST YEAR? IF YES, PLEASE PROVIDE THE FOLLOWING:
NAME OF FINANCIAL INSTITUTION
CHECKING
SAVINGS
MONTH & YEAR CLOSED
AMOUNT IN ACCOUNT AT TIME OF CLOSING
6. HAVE YOU MADE ANY PAYMENTS OVER $600.00 IN THE PAST 90 DAYS TO ANY ONE CREDITOR? (THIS EXCLUDES HOUSE NOTES OR CAR NOTES) IF YES PLEASE PROVIDE THE FOLLOWING:
CREDITOR'S ADDRESS
AMOUNT PAID
EXPLANATION OF PAYMENT
DATE OF PAYMENT

MonthDayYear
Date
7. DO YOU HAVE IN YOUR POSSESSION PROPERTY OWNED BY ANOTHER PERSON THAT YOU ARE HOLDING OR USING? IF YES PLEASE PROVIDE THE FOLLOWING:
DESCRIPTION OF PROPERTY
NAME OF PERSON WHO OWNS SAID PROPERTY:
ADDRESS OF PERSON WHO OWNS SAID PROPERTY:
8. DO YOU HAVE AN UNEXPIRED LEASE WITH ANYONE? (AUTOMOBILE LEASE, APARTMENT LEASE, ETC.) PLEASE PROVIDE THE FOLLOWING:
NAME OF COMPANY
COLLATERAL BEING LEASED
LENGTH OF LEASE
WHEN DOES LEASE END
IF YOU DO NOT LEASE OR OWN A HOUSE / APARTMENT, WHO IS THE OWNER OF THE PROPERTY WHERE YOU CURRENTLY LIVE IN?
9. HAVE YOU USED ANY CREDIT CARD TO OBTAIN CASH IN THE PAST 90 DAYS?
10. HAVE YOU USED ANY CONVINIENCE CHESKS FROM CREDIT CARDS IN THE PAST 90 DAYS?
11 HAVE YOU DONE ANY BALANCE TRANSFER FROM ONE CREDIT CARD TO ANOTHER CREDIT CARD IN THE LAST YEAR?
12 DO YOU STAND TO INHERIT ANY PROPERTY WITHIN THE NEXT SIX MONTHS
13 ARE YOU ENTITLED TO A TAX REFUND IF SO HOW MUCH
AUTHORIZATION
By signing this, I do hereby authorize the law office of William J Casey, II to pull my credit reports
Signature

Clear
Debtors Name
date

MonthDayYear
Date
Debtors Name
date

MonthDayYear
Date
Should be Empty:

IMPORTANT QUESTIONS

GENERAL INFORMATION

MARITIAL STATUS:

TELEPHONE NUMBERS: HOME:

SPOUSE INFORMATION: (IF FILING JOINT)

NAMES AND AGES OF CHILDRE LIVING WITH YOU:

IF CHECKED YES PLEASE PROVIDE THE FOLLOWING INFORMATION:

CREDITOR'S NAME: CREDITOR'S ADDRESS:

AMOUNT OF CLAIM DO YOU WISH TO KEEP THIS CLAIM

CURRENT INCOME OF INDIVIDUAL DEBTOR(S): DEBTOR 1

DEBTOR 2 OR NON FILING SPOUSE

PLEASE PROVIDE THE FOLLOWING INFORMATION: AMOUNT OF GROSS INCOME FROM EMPLOYMENT FOR THE LAST TWO YEARS INCLUDING WHAT YOU HAVE MADE YEAR TO DATE.

DEBTOR 1

CURRENT MONTHLY EXPENSES

DO YOU HAVE ANY GARNISHMENTS AGAINST YOU? IF YES, PLEASE LIST THE FOLLOWING:

QUESTIONS FOR STATEMENT \ OF FINANCIAL AFFAIRS (MUST BE ANSWERED)

AUTHORIZATION