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Law Offices of Mark H. Avery P.O. Box 862 phone: 781 294 7855 fax: 781 294-7436
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BANKRUPTCY
QUESTIONNAIRE
If you are filing a joint bankruptcy or if you live with your spouse and
are filing chapter 13 answer the questions for both yourself and your
spouse. Thank you. PART ONE -
BASIC INFORMATION YOU
YOUR SPOUSE 1. a.
Name: a. b. Other names (i.e. maiden, trade name, etc.): b. c. Social Security Number c. d. Address e. Mailing address f. Telephone Number day
: evening
: 2. Are you filing bankruptcy yourself or with
your spouse? 3. Have you, your spouse, or a business partner
filed bankruptcy within the past 6 years?
If so, please give the name and docket number of the case and the date
it was filed. PART TWO -
ASSETS & LIABILITIES A. Real Property 1. List the addresses of all real property that
you own. List the name that the
property is owned in (i.e. you, you and
your wife, you and someone else, etc.) 2. List the Fair
market Value and include a copy of your tax bill or an appraisal for each piece
of real property (homes, land,
condominiums) with this questionnaire. 3. List the Mortgages
on each property together with the complete address of the Mortgage
Holder and the principal balance due on each mortgage. Property Address
Mortgage Holder Address
Principal Balance Due B. Personal
Property: 1.
How much cash on hand do you have? 2. List bank accounts, together with
account balances. Bank/Financial
Institution Account
No./Type Account Balance 3. Do you have security deposits
with anyone? If so state the name of
the person with the deposit and the amount.
(i.e. rental deposit) 4. Give an estimate of the fair
market value (yard sale price) of your household belongings. 5. Do you have any collections (i.e.
coin, stamp, antique, etc.)? If you do give the type and value of each
collection. Give estimates of the value of the
following (questions 6-33): 6. your wardrobe 7. furs & jewelry 8.
firearms, sports equipment, photo & hobby equipment 9.
List insurance policies that you own. Company Name Surrender or Refund Value 10. List any annuities that you own with the name and value of
each. 11.
List all pensions that you have (i.e. IRA, Keogh, etc.) Pension Name Value ERISA qualified? (if you do not know
if your pension is ERISA qualified ask your pension administrator) 12. List stocks you own with the
value of each. 13. List interests you have in
partnerships or joint ventures 14. List Bonds that you own with the
value of each 15. Does anyone owe you money?
(accounts receivable) List each. 16. Are you entitled to money or
property from a divorce? Describe 17. Are you entitled to a tax
refund? How much? 18. Do you have any future
interests, life estates etc. (if
you do not know what one is, you probably do not have one) 19. Are you entitled to an
inheritance, insurance proceeds, or other benefit due to a death? Describe 20. Do you have any lawsuits or the
possibility of a lawsuit against someone? Describe 21. Do you own any patents or
copyrights? Describe 22. Do you have any special license
(i.e. liquor, food)? Describe 23.List any vehicles you own: Year Make Model Fair Market Value 24. List any boats 25. List any aircraft 26. Do you have
office equipment? List each piece with value 27. Do you have
business machinery? List each piece with value 28. Do you have
inventory? Describe with value 29. Do you own
animals other than pets? Describe and
include value 30. Do you have
crops? 31. Farming
equipment? 32. Farm
supplies? 33. Any other
property not listed above? D.
Secured Creditors List the names and addresses of anyone who is
financing any of your property (i.e. car loan, second mortgage etc.)(include copy
of statement if available) Creditor Name &
Address Item Financed Amount Owed Value of Property E.
Priority Debts 1. Do you owe anyone wages or the return of a
security deposit? If yes, give details. 2.
List any amounts that you owe for taxes, interest or penalties to the I.R.S.,
state taxes, real estate taxes, or excise taxes. State the year the amount due is from (i.e. $3,000 1994 income
taxes $2,000 penalties and interest
IRS)(include copies of any notices) F.
Unsecured Debts. Make a list or
give a copy of your bills showing the account numbers, addresses
and balances for all of your credit cards, medical bills, loans
and other debts. State whose name the
debt is in if you are filing a joint
bankruptcy. G. Leases 1.
If you rent your home or office, give the name and address of your
landlord, together with the address of the rented property and the amount of
the rent. 2. If you lease a car, other vehicle
or any other property, state the name
and address of the company you lease from, a description of the leased vehicle
and the lease amount. H.
CoDebtors Of any of the debts
listed, does anyone else owe the money with you (i.e. a cosigner, guarantor,
etc.) State the name and address of
the codebtor and the name and address of the creditor. I. Income 1. List your marital
status (single, married, divorced) and the names, and ages of your children or
other dependents. (If you are filing a
joint petition or chapter 13, include information for your spouse for
questions 2-4.) 2. State your
occupation, and the name and address of your employer, and how long you have
worked there. 3. State your monthly
gross income (before taxes), and your
monthly take home pay (after all deductions).
State how much is regular pay and how much is overtime. 4. List your monthly
deductions and what the deductions are for.
(i.e. taxes, medical insurance, union dues, 401K plan, etc.) TAXES INSURANCE PENSION OTHER (Describe) 5. List any other income that you have,
stating the income monthly, and the source of the income. (i.e. rental income, child support,
interest, pension, social security, AFDC, etc.) For questions 2 - 5,
if you need to figure the monthly amount;
for a weekly item multiply by 4.3, for a biweekly item multiply by 2.15
and for yearly items divide by 12.
Consult your paystub, bills or other documents for the figures. Please
enclose copies of your paystubs for an average weeks work from each job. (i.e. if you work 40 hours, enclose a copy
of a 40 hour work week paystub) J. Expenses List your monthly expenses: 1. Rent or home
mortgage payment Are real estate taxes included in the
mortgage? Is property insurance included in the
mortgage? 2. Utilities a.
electric & heating fuel
b.
water & sewer c. telephone d.
cable t.v. 3. Home maintenance 4. Food 5. Clothing
6. Laundry & dry cleaning 7. Medical and dental
expenses 8.
Transportation (gas, etc.,not car payments) 9. Recreation &
entertainment 10.
Charitable Contributions 11. Insurance a. homeowners or renters b. life c. auto d.
other 12. Taxes (not
deducted from wages or included in your mortgage payment) 13. Installment
payments a.
auto
b. second auto
c. list any other 14. Alimony or child
support 15. Any other regular
expenses Total: PART III -
DECISIONS TO KEEP OR RETURN PROPERTY A. 1. For property that you make monthly payments
on, list what property you wish to keep: 2.
Do you wish to continue to make payments, or can you pay for the full value of
the item. (i.e. if your car is worth
$2,000 and you owe $3,000 you may continue making monthly car payments or pay
the fair market value of $2,000) B. 1. For property that you make monthly payments
on, list what property you wish to give back: 2.
When can the creditor pick the item up? PART IV YOUR
FINANCIAL AFFAIRS 1. What was your income from your
jobs) for each of the past two years?
What has your income been so far this year? 2. Have you earned income from a
source other than your job? List your
income for the past two years from other sources and state where it came from. 3. a.
Have you paid any creditor over $600 within the past three months? If you have give the name and address of the
creditor, the amount paid, and the date(s) b.
Have you paid any relative or business associate money owed to them within the
past year? If you have give their name
and address, the amount paid, and the date(s) 4.
a. Have you been in any lawsuits within the past year? If you have, state the case name and number,
the court that it is in, and a brief summary of the case. b.
Has any of your property been attached, garnished or seized within the last
year? 5. Has any of your property been
repossessed, foreclosed on or returned? 6. Have you assigned any of your
property within the last 6 months or placed it with a receiver. If any of questions
4b-6 is yes, state the name and address of the person with the property, what
the property was and its value. 7.
Have you made any gifts or contributions of over $200 in value? 8. Have you had any losses from
fire, theft, gambling or other casualty.
If you have what was lost, what was the value, what was the date of the
loss and are you expecting insurance proceeds? 9. Have you paid anyone else for
debt counseling or bankruptcy within the past year? If you have give the
persons name and address, the amount paid and the date. 10. Have you transferred any other
property to anyone within the last year.
Give details . 11 Have you closed any bank accounts
within the last year? If you have list
the account, the final balance and the date you closed the account. 12. Do you have any safety deposit
boxes or did you within the last year? If you do, where is it, and what is in
it and if you did, where was it, what was in it, and when was it removed? 13. Has any bank taken money from
any of your accounts within the last three months for money that you owed (a
setoff) 14. Are you holding property for
anyone else? If you are, who owns it,
what is it and how much is it worth? 15. List all your addresses within
the last two years, with the dates you lived there. (You do not need to include your present address) 16. If you are in business with a
partner, corporation, or self employed be sure to request and complete the
Supplemental Questionnaire. |