Bankruptcy Questionnaire

This is your Bankruptcy Questionnaire. Please fill it out carefully.
Full Name

First NameLast Name
Date of Birth?

MonthDayYear
E-mail
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
1. Have you lived here for at least 2 years?*
2. Are you Married?*
If you are separated please answer yes.
Have you been separated or divorced in the last 10 years?*
3. Do you have children you support financially?*
This would include any children in college.
If Yes:
4. Have you ever filed for Bankrtupcy Before?*
If yes, when?
5. Do you own any Real Estate?*
This includes: Time Shares, & property outside the USA
6. How much cash do you have in your wallet?*
7. Is your Landlord or Untility company holding a security deposit?*
8. Please check what you own for household goods:

Living room setBed room setDining room setMiscellaneous other furnitureComputer, TV'sOther items listed below
Value of all items?*
9. Please list the value of your books, pictures, cd's, art objects, & collectables.*
10. Please list the value of your summer & winter clothing.*
10. Please describe & list the value of your furs & jewelry.*
11. Please describe & list the value of your sports, hobby equipment, firearms.*
12. Do you have life insurance?*
13. Do you receive an annuity?*
14. Do you have an IRA?*
15. Do you have a 401k, or 403(b)?*
16. Do you have interest in a pension or profit sharing plan?*
17. Do you (or through someone else) have an interest in a life estate, future interest, insurance plan or trust?*
18. Do you own any stocks or bonds?*
19. Do you own a business?*
20. Do you receive child support or alimony?
If Yes How Much monthly?
21. How much do you usually get for a tax refund?*
$
22. Do you have a patent, copyrights, or other intellectual property?*
23. Do you have a car?*
If Yes, please include Year, Make, Model, & Miles*
24. Please check what other property you own below:*

BoatATV2nd CarMotorcycleFarm EquipmentAnything else not listedNONE
Indicate value of each item.
25. Please list your profession & how long you've been employed (include your spouse)
26. Please list anyone that contributes towards your household finances
27. Do you receive any money for any other sources?
The next section will ask you about

your monthly expenses. Please use monthly amounts
Rent or Home MTG
Do you have a 2nd home
Water & Sewer
Electricity & Heating
Home maintenance, repairs, upkeep.
Home association or condo fees
Home Phone Expense
Cell Phone Expense
Cable & Internet
Food & Housekeeping supplies
Other insurance?
Childcare & Education costs
Clothing, laundry, dry cleaning
Transportation costs, including gas
Personal hygiene expenses
Recreational entertainment
Charitable contributions
Monthly Car Payment
Car Excise Tax
Car Insurance
Health insurance
If not deducted from paycheck
Life insurance
If not deducted from paycheck
Other insurance?
IRS / State Taxes?
Student loan payments
This is the last section to the questionnaire. This should take less than five minutes to comeplete. Please type your responses with "Yes" or "No" and explain if necessary.
28. Other than your rent, mortgage payment, or car payment, have you paid any one creditor more than $600 in the past 90 days?*
29. Within the last year, have you paid any family members or close friends more than $500 other than normal holiday or birthday gifts?*
30. Has anyone sued you in Court the last year?*
31. Do you have any law suits you plan on filing?*
32. In the past two years have you had any property that has been garnished, seized, repossessed, or foreclosed on?*
33. Is anyone holding any assets for you, or are you holding any assets for anyone else?*
34. Have you made any charitable gifts more than $200 in the last year?*
35. Do you have any type of losses from either gambling, fire, theft, or the like from the past year?*
36. Have you transferred any type of property in the past two years?*
37. Are you the beneficiary of a trust or do you have a trust?*
38. Have you closed any financial accounts in the last year?*
39. Do you have a safe deposit box?*
40. If you have NOT lived at your current address for the past 3 years, please list your previous address?
Please sign indicating that you have answered the following questions truthfully & to the best of your ability. *

Clear
Should be Empty:

This is your Bankruptcy Questionnaire. Please fill it out carefully.