Bankruptcy Questionnaire for Business Debtor

Client Questionnaire for Business Debtor
Section 1

Basic Information
Part A:

Name and Address
Name of business*
Your Name*

First NameLast Name
Your email address*
example@example.com
Contact Person's Telephone Number*
ext.
Has the business gone by any other names in the past six years?

No
Other Business names in the past six years?
Federal Tax ID
Business Address (official business address at Secretary of State)

Street

Street Address Line 2

CityState

Zip
Address where principal assets of business are located? (if different from above)

Street

Street Address Line 2

CityState

Zip

Part B.

Nature of Business
Please describe the nature of your business
Who is the Authorized Signor for the Business

First NameLast Name
His/Her title?
(president, manager, etc.)
Part C.

Prior/Pending Bankruptcy Cases
Has this company been in bankruptcy in the last 6 years?

YesNo
If yes, in which state was the case filed?
Case Number
Date filed

MonthDayYear
Date
Are there currently any bankruptcy cases pending involving you, your business, your business partner, or any of your affiliates?

NoYes
Name of the debtor in the pending bankruptcy case
Relationship to this business.
(affiliate, partner, etc)
Case Number
Date filed

MonthDayYear
Date
State in which the case was filed
Does your company own or have possession of any property that poses or is alleged to pose a threat of imminent and identifiable harm to public health or safety or maintain records that are protected by HIPAA?

NoYes

Section 2

Property
Part A

Real Estate (Schedule A)

List all real estate which the business owns or is a joint owner of, even if the business still owes money on the property.

	Address of Property	Market Value	Mortgage Holder (name & address)
1.
2.
3.

Part B

Personal Property (Schedule B)
For each type of property listed below, indicate whether the business owns any property of that category, and, if so, fill in the remaining information. You can think of the market value as the resale value.
Cash:
Amount of Cash on Hand

Bank Accounts in Business' Name

	Name of Bank	Last 4 digits of Account #	Balance
1
2
3
4
5

Security Deposit held by utility companies or landlord (one per line)
(name of party - amount of deposit) ex. Joe Landlord - $20,000
Value of Uniforms and Clothing
Estimated value of Uniforms and Clothing (if none, type "none")
Insurnace: cash in value for any company owned insurance policies
type "none" if none
List all stock or interest owned in another business.
or "none"
List all other businesses that this business is in a partnership with:

Value of Bonds owned by Company
Total amount of Accounts Receivable
Total amount of debts owed to business from any source (other than accounts receivable)
Describe any lawsuits that the company can file against another party (not related to accounts receivable)
name the party and a brief description (ie. Jane employee stole $5000)
List all intellectual property owned by company.
websites, patents, trademarks, etc.
List all Licenses of Value that are owned by the Business
ie. liquor license, franchise agreements etc.
List all Automobiles, trucks, trailers etc. owed by the Business
Make, Model, Year and mileage
List all Boats, motors, trailers and accessories owed by the Business
Make, Model, Year
Office Equipment & Furnishings
List office equipment and furnishings owned by business and estimated value.
Business Machinery & Fixtures
List machinery and fixtures owed by business
Value of Unsold Inventory
What is the wholesale value of all inventory on hand?
Property Not Listed
List all property owned by the business that is not already listed.

Section 3

Company Debts
List below all debts that the business owes, or that creditors claim that the business owes. If you need more space, you can add later.

NOTE: if you need more space than is provided, please prepare a spreadsheet and email it to us.

Mortgages on Real Property

	Name/Addressof Mtg. Co.	Balance Owed	Address of Property	Amount of Arrears
1
2
3
4

Are there more mortgages than are listed above?

Yes - MoreNo

Vehicle Loans

	Name/Address of Loan Co.	Balance Owed	Make/Model of vehicle	Amount of Arrears
1
2
3
4

Are there more vehicle loans than are listed above?

Yes - MoreNo

Other Bank Loans (ie. SBA Loan)

	Name/Address of Loan Co.	Balance Owed	Describe Collateral (if any)	Is debt personally guaranteed?
1
2
3
4

Are there more bank loans than are listed above?

Yes - MoreNo

Non-Bank Loans (ie. Friends, investors, shareholders)

	Name/Address of Lender	Balance Owed	Is debt personally guaranteed?
1
2
3
4

Are there more non-bank loans than are listed above?

Yes - MoreNo

Business Credit Cards (do not list personal credit cards that you used for the business)

	Name/Address of Lender	Balance Owed	Name of co-debtor or guarantor
1
2
3
4
5
6

If you have more credit cards that there is space listed above, please prepare a spreadhseet with the information listed above and email it to us.

Unpaid Utility Bills

	Name/Address of Provider	Balance Owed
1
2
3
4

Unpaid Rent(s)

	Name/Address of Landlord	Balance Owed
1
2
3

Unpaid Tax(es)

	Name of Gov. Agency (IRS, DOR)	Balance Owed	Type of Tax (sales, withholding, etc)
1
2
3

Unpaid Professional Fees (accountants, attorneys, etc.)

	Name of Creditor	Balance Owed	What is it for?
1
2
3

Trade Debt (owed to suppliers, etc.)

	Name of Creditor	Balance Owed	What is it for?
1
2
3

All other Debt (employees, profit sharing, etc.)

	Name of Creditor	Balance Owed	What is it for?
1
2
3

Section 4

Unexpired Contracts
List below any leases or contracts that are still current that the business is a party to. Include real estate, car and business leases, and any unfulfulled contracts that the business currently owes services or product to clients.

All other Debt (employees, profit sharing, etc.)

	Description of Contract	Other Party's name & Address
1
2
3
4
5
6

Section 5

Statement of Financial Affairs
If you have no information to report for a question, check the "NONE" box.

GROSS REVENUES (if none, state "NONE")

	Amount
This Year to Date
Last Year
Year before Last

List all payments to creditors in the last 90 days:

None
Name of creditor - Total of payments in last 90 days.
List all Payments made to Business owners, partners, officers or their families within the last year.

None
Name person who was paid and the total amount paid to them (do not list regular salaries paid).
List all Lawsuits that the business was a party during the last year.

None
Case name, docket, where filed, and type of case (ex. Smith v. ABC Corp. - Boston District Court - breach of contract.)
List all property that has been repossessed, foreclosed or seized in the last year

None
provide the name of the creditor, property that was seized and the date it was seized.
Describe any assignment of property for the benefit of creditors made within 120 days immediately preceding the commencement of this case.

NONE
name of assignee and date of assignment

List all property which has been in the hands of a custodian, receiver, or court-appointed official within one year immediately preceding the commencement of this case.

NONE
name and address of custodian and description of property
Losses List all losses from fire, theft, or other casualty within one year immediately preceding the commencement of this case or since the commencement of this case.

NONE
description and value of property, date of loss and circumstances of loss
Other transfers, (including sale of business property) List all other property, other than property transferred in your ordinary course of business or financial affairs, transferred either absolutely or as a security within the last year.

NONE
description of property, name of party transferred to and value of property
Closed financial accounts List all financial accounts and instruments held in your name or for your benefit which were closed, sold, or otherwise transferred within one year immediately preceding the commencement of this case.

NONE
name of institution - type of account - account # - balance when closed
Setoffs List all setoffs made by any creditor, including a bank, against a debt or deposit of yours within 90 days preceding the commencement of this case.

NONE
name of creditor, date of setoff, amount of setoff
Property held for another person List all property that you hold or control that is owned by another person.

NONE
name of owner, description of property, location of property

Environmental Information. For the purpose of this question, the following definitions apply: "Environmental Law" means any federal, state, or local statute or regulation regulating pollution, contamination, releases of hazardous or toxic substances, wastes or material into the air, land, soil, surface water, groundwater, or other medium, including, but not limited to, statutes or regulations regulating the cleanup of these substances, wastes, or material. "Site" means any location, facility, or property as defined under any Environmental Law, whether or not presently or formerly owned or operated by the debtor, including, but not limited to, disposal sites. "Hazardous Material" means anything defined as a hazardous waste, hazardous substance, toxic substance, hazardous material, pollutant, or contaminant or similar term under an Environmental Law
a. List the name and address of every site for which you received notice in writing by a governmental unit that it may be liable or potentially liable under or in violation of an Environmental Law. Indicate the governmental unit, the date of the notice, and, if known, the Environmental Law

NONE
site name and address, gov. unit name and what enviromental law
b. List the name and address of every site for which you provided notice to a governmental unit of a release of Hazardous Material. Indicate the governmental unit to which the notice was sent and the date of the notice.

NONE
site name and address, gov. unit name and what environmental law
c. List all judicial or administrative proceedings, including settlements or orders, under any Environmental Law with respect to which you are or were a party. Indicate the name and address of the governmental unit that is or was a party to the proceeding, and the docket number.

NONE
site name and address of gov. unit, Docket #, Status of case

Nature, location and name of business
a. If the debtor is a partnership, list the names, addresses, taxpayer identification numbers, nature of the businesses, and beginning and ending dates of all businesses in which the debtor was a partner or owned 5 percent or more of the voting or equity securities, within the six years immediately preceding the commencement of this case. If the debtor is a corporation, list the names, addresses, taxpayer identification numbers, nature of the businesses, and beginning and ending dates of all businesses in which the debtor was a partner or owned 5 percent or more of the voting or equity securities within the six years immediately preceding the commencement of this case.

NONE
Name - Tax ID No. - Address - Nature of Business - Start and end Date
b. Identify any business listed in response to subdivision a., above, that is "single asset real estate" as defined in 11 U.S.C. § 101.

NONE
Name - Address

Business Records
List all bookkeepers and accountants who, within the six years immediately preceding the filing of this bankruptcy case, kept or supervised the keeping of books of account and records.

NONE
Name - Address - dates services rendered
List all firms or individuals who, within the two years immediately preceding the filing of this bankruptcy case, have audited the books of account and records, or prepared a financial statement of the debtor.

NONE
Name - Address - dates services rendered
List all firms or individuals who, at the time of the commencement of this case, were in possession of your books of account and records. If the records are not available, explain.

NONE
Name - Address - dates services rendered
d. List all financial institutions, creditors and other parties, including mercantile and trade agencies, to whom a financial statement was issued by the debtor within two years immediately preceding the commencement of this case.

NONE
Name - Address - dates services rendered

Inventories
List the dates of the last two inventories taken of your property, the name of the person who supervised the taking of each inventory, and the dollar amount and basis of each inventory.

NONE
Date of Inventory - Dolar amount of inventory
List the name and address of the person possessing the records of each of the two inventories reported in a above.

NONE
Date of Inventory - Name and Address of custodian of records

Current partners, officers, directors, and shareholders
Partnership & LLC: If your business is a partnership, or an LLC list the nature and percentage of partnership interest of each member.

NONE
Name & Address, Nature of interest and percent ownership
Corporation: list all officers and directors of the corporation, and each stockholder who directly or indirectly owns, controls, or holds 5 % or more of the voting securities of the corporation.

NONE
Name & Address, Title, Percentage of stock ownership
Former partners, officers, directors and shareholders: If your business is a partnership, list each member who withdrew from the partnership within one year immediately preceding the commencement of this case.

NONE
Name & Address, Date of Withdrawal
Corporation: list all officers or directors whose relationship with the corporation terminated within one year immediately preceding the commencement of this case.

NONE
Name & Address, Title, Date of Termination
Withdrawals from a partnership or distributions by a corporation: If your business is a partnership or corporation, list all withdrawals or distributions credited or given to an insider, including compensation in any form, bonuses, loans, stock redemptions, options exercised and any other perquisite during one year immediately preceding the commencement of this case.

NONE
Name & Address of recipient, and relation to you, Date of Withdrawal, Amount of money withdrawn
25. Pension Funds. List the name and federal taxpayer identification number of any pension fund to which the debtor, as an employer, has been responsible for contributing at any time within the six-year period immediately preceding the commencement of the case.

NONE
Name of Pension Fund - Tax ID #
Should be Empty:

Client Questionnaire for Business Debtor

Section 1

Part A:

Part B.

Part C.

Section 2

Part A

Part B

Section 3

Section 4

Section 5

Inventories

Current partners, officers, directors, and shareholders