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BANKRUPTCY WORKSHEET INSTRUCTIONS

Please go through these worksheets carefully. Provide as much information as you can. Fill out what applies and cross out the rest. If you need more sheets, most of the forms are designed to be duplicated. If necessary, attach a sheet and label it, for example: "Client Info cont'd, Other Names Used in Past 6 Years".

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1. PETITION-1

What names have you have been known by, including maiden names, during the last 6 years?__________________

What business and trade names have you used during the last 6 years._____________________________

Spouse section: to be filled out by clients filing as husband and wife.  What names and /or business or trade names have you used in the last 6 years?________________________________________________

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2. SECURED CLAIMS

These sheets are designed to enter one secured creditor per page. Get as many sheets as you need. Number them at the top right as follows: 1 of 5 i.e. tell how many sheets there are.  If you have a copy of your bill and/or a contract please bring it with you.; Any information on the bill and/or contracts will not have to be duplicated. If you have a copy of your bill, we only need you to write down a few additional items: 1. when the debt was incurred (year); 2. Interest rate if debt is secured; 3. What asset secures debt? 4. Give us a copy of the contract that got you into the debt.

If you are filing for Chapter 13: For each secured debt, we need to know themonthly payment, and if the payments are current or how far behind you are. If you want to keep the property, the amount of the monthly payment should also appear on the Budget Sheet. You are asked for the which is either real estate (land and buildings)or personal(anything but real estate). For personal property, family:"Courier New"">write in the category number, using the "Key to Property Categories". Of course, if you list a property on a secured claims sheet, you don't list it again on an "owned free and clear. Sometimes a lender will take a lien against several properties, such as a second mortgage on your house and liens on your car, your stereo and your shop tools. When this happens, separately list each value, property type and category. However, if there is a second mortgage or third mortgage on your house, or if any other property has more than 1 lien on it, enter each additional debt as a separate secured creditor, even if these additional debts are to the same lender. (But the mere fact that a debt is in arrears, or has had penalties added to it doesn't make it two debts. Market Value: See property owned free and clear. Codebtor: in community property states, the spouse must be listed as codebtor, including alias and maiden names) even if not a party to the bankruptcy filing. 3. PRIORITY DEBTS These sheets are designed to enter one creditor per sheet. Get as many as you need and number them at the top right as follows: i.e. tell how many sheets there are. Priority claims are debts owed to the Government (taxes, fines, water & sewerbills), to employees for Wages or fringe Benefits (including pension, contributions), to customers who made Deposits for personal or household purchases, or to Farmers or fishermen for grain or fish you purchased. Some priority debts, such as most taxes, will survive the bankruptcy and mustbe paid off later. Please attach a copy of your most recent statement for each debt. You have the right to "reaffirm" any priority or unsecured debts. A reaffirmed debt survives the bankruptcy as a personal obligation of yours, and thecreditor can sue you to enforce payment. If, for some reason, you want to reaffirm a debt, please indicate in the box below. 4. UNSECURED DEBTS These sheets are designed to enter one creditors per sheet. Again, get as many as you need and number them at the top right as follows: how many sheets there are. Please list all debts you have not already listed as a secured or priority debt. These lists are used to give creditors notice of your bankruptcy. A creditor must get notice of your bankruptcy, or his claim will not be discharged. You must be complete and accurate with all addresses. If you are not sure of the exact amount owed, list your best guess. It is more important that a creditor get notice of your bankruptcy than that the amount listed as owed be 100% accurate. Be sure to list such debts as child support and maintenance (alimony)arrearages, student loans, delinquent utility bills, loans you co-signed or guaranteed (even if the loan is not in default). Some of these debts are not dischargeable in bankruptcy, and other debts you might want to pay off in spite of the bankruptcy. Nonetheless, you should list all these debts. If you want to reaffirm any debt -- take it on as a personal obligation which can be enforced against you in court -- please indicate in the box below. Please attach a copy of your most recent statement for each debt. 5. PROPERTY OWNED FREE AND CLEAR List here all real estate and personal property that you have not already listed as collateral on a Secured Claims sheet. To help you remember all property, you may wish to go room-by-room. Then go down the Key To Property Categories; list to be sure you have missed nothing.The market value of most of your household goods is the price you could sell them for at a garage sale. For antiques, cars, business equipment and the like, you might need to consult a dealer as to the value -- the price you could sell it for in a reasonably short time period. The value is the amount YOU can get, not what a dealer would charge. It does not matter that the Blue Book retail value" of a car is $10,000 if the dealer will give you only $7500 cash for it. Items with an individual value of less than $50 you may lump together for the sake of convenience. If an individual item is worth $50 or more, please list it separately. For example, microwave oven; and dishes and cookware, pensions, insurance policies, bank accounts and child support or maintenance (alimony) arrearages due you. 6. EXECUTORY CONTRACTS Executory contracts are leases -- ongoing agreements in which something more than just payment of money remains to be done. This includes all leases -- for your apartment, car, water softener, etc. It does not include installment loans. The form is designed to hold two items per sheet. Again, get as many as you Number them like the creditor sheets 7. BUDGET Income Section Chapter 7/11: filers must fill out both debtor and spouse columns chapter 12/13: married debtors must fill out both columns unless separated and filing as individuals. Expenses Section You must fill out separate debtor and spouse columns only if you are separated but filing jointly. 8. STATEMENT OF FINANCIAL AFFAIRS Consumer debtors need answer only questions 1 through 18. Married persons filing as individuals under chapter 12 or 13 must provide information for their spouse unless the parties are separated. A person engaged in business during the 2 years preceding this filing, as a sole proprietor, partner, family farmer, or self-employed professional must also answer questions 19 to 25. 9. 20 LARGEST UNSECURED CREDITORS This applies only to chapter 11 business bankruptcy filings. The purpose is to tell, for the 20 largest unsecured claims, how to reach that creditor's contact: name, address and phone. If the name and address are the same as on the creditor's sheet, so that you only need to enter the phone, you can put that on the appropriate creditor sheet and not bother here. If the name or address are different, you must enter them here. No distinction is made between priority and non-priority creditors. Also, the list may include secured creditors if they are not fully secured and the unsecured portion of their claim is large enough to put them in the top 20. Again, you may duplicate additional sheets if needed and number them. 10. EQUITY SECURITY HOLDERS This applies only to chapter 11 corporate bankruptcy filings. For each equity security holder, enter number and type of shares or other type of interest. Again, you may duplicate additional sheets if needed. 11. KEY TO PROPERTY CATEGORIES Use the following list when you are asked for the "Property Type". If the property type is real estate, enter; Cash on hand. Checking, savings or other financial accounts, certificates of deposit, or shares in banks, savings and loan, thrift, building and loan, and homestead associations, or credit unions, brokerage houses, or cooperatives. Security deposits with public utilities, telephone companies, landlords, and others. Household goods and furnishings, including audio, video, and computer equipment. Books, pictures and other art objects, antiques, stamp, coin, record, tape, compact disc, and other collections or collectibles. Wearing apparel. Furs and jewelry. Firearms and sports, photographic, and other hobby equipment.Interests in insurance policies. Name insurance company of each policy and itemize surrender or refund value of each. 10. Annuities, itemize and name each issuer. Interests in IRA, ERISA, Keogh, or other pension or profit sharing plans. Itemize. Stock and interests in incorporated and unincorporated businesses. Itemize. Interests in partnerships or joint ventures. Itemize. Government and corporate bonds and other negotiable and non-negotiable instruments. Accounts Receivable. limony, maintenance, support, and property settlements to which the debtor is or may be entitled. Give particulars.Other liquidated debts owing debtor include tax refunds. Give particulars. Equitable or future interests, life estates, and rights or powers exercisable for the benefit of the debtor other than those listed in Schedule of Real Property. Contingent and non-contingent interests in estate of a decedent, death benefit plan, life insurance policy, or trust. Other contingent and un-liquidated claims of every nature, including tax refunds, counterclaims of the debtor, and rights to setoff claims. Give estimated value of each. Patents, copyrights, and other intellectual property. Give particulars. licenses, franchises, and other general intangibles. Give particulars. Automobiles, trucks, trailers, and other vehicles. Boats, motors, and accessories. Aircraft and accessories. Office equipment, furnishings, and supplies. Machinery, fixtures, equipment and supplies used in business. Inventory. Animals. Crops--growing or harvested. Give particulars. Framing equipment and implements. Farm supplies, chemicals, and feed. Other personal property of any kind not already listed. Itemize. SECURED CLAIMS, Schedule D Creditor Name: ___________________________________________________________ Address:___________________________________________________________ Line 2:___________________________________________________________ Line 3:___________________________________________________________ Account Number: __________________ Collection Agency: ___________________________________________________________ Address:___________________________________________________________ Line 2:___________________________________________________________ Line 3:___________________________________________________________ Amount of Debt: $_________________ Unsecured Portion: $_________________Chapter 13: Regular Pmts:$_____________ ; Continue Pmts: [ ]Yes [ ] No Interest Rate:__________% Delinquent:$________________ When Incurred: _________________ By Whom: [ ]Husband [ ]Wife Joint Community Nature of Lien: [ ] Common Law [ ]Deed of Trust [ ] Garnishment []Judgment [ ] Mechanic's Lien [ ] Mortgage [ ] Purchase Money [ ] Statutory [ ] Other:____________ Are there OTHER LIENS against the securing property: [ ] Yes [ ] No (Make out a sheet for each.)Codebtors' Name: ___________________________________________________________ Address:___________________________________________________________ Line 2:___________________________________________________________ Line 3:___________________________________________________________ Conditions:[ ] Contingent [ ] Disputed [ ] Unliquidated Property Type: ____________________________(Use Category Listing Sheet)Property Description: ________________________________________________________ Line 2:___________________________________________________________ Line 3:___________________________________________________________ Market Value: $_________________Intention: [ ]Reaffirm [ ]Surrender [ ]Redeem [ ]Avoid [ ]None (Choose One) Other:_______________________________________________________ SECURED CLAIMS, Schedule D Creditor Name: ___________________________________________________________ Address:___________________________________________________________ Line 2:___________________________________________________________ Line 3:___________________________________________________________ Account Number: __________________Collection Agency: ___________________________________________________________ Address:___________________________________________________________ Line 2:___________________________________________________________ Line 3:___________________________________________________________ Amount of Debt: $_________________ Unsecured Portion: $_________________Chapter 13: Regular Pmts:$_____________; Continue Pmts: [ ]Yes [ ] No Interest Rate:__________% Delinquent:$________________ When Incurred: _________________ By Whom: [ ]Husband [ ]Wife Community Nature of Lien: [ ] Common Law [ ]Deed of Trust [ ] Garnishment [ ] Judgment [ ] Mechanic's Lien [ ] Mortgage [ ] Purchase Money [ ] Statutory [ ] Other:____________ Are there OTHER LIENS against the securing property: [ ] Yes [ ] No (Make out a sheet for each.)Codebtors'Name: ___________________________________________________________ Address:__________________________________________________________Line 2: ___________________________________________________________Line 3: ___________________________________________________________Conditions: [ ] Contingent [ ] Disputed [ ] Unliquidated (Use Category Listing Sheet)Property Description: ________________________________________________________Line 2: ___________________________________________________________Line 3:___________________________________________________________Market Value: $_________________Intention: [ ]Reaffirm [ ]Surrender [ ]Redeem [ ]Avoid [ ]None (Choose One)Other: _______________________________________________________ Real Personal Property, Schedules A, B, C Property type: [ ] Real Estate [ ] Personal-#___ on category listing sheet. Description: ___________________________________________ Value$ __________ H/W/J/C Line 2:____________________________________________________________________Location:_____________________________________________________________________ Line 2:____________________________________________________________________Exempt: $____________________ Spouse: $_____________________Office Use: cite number on citation list: ________________ Property type: [ ] Real Estate [ ] Personal-#___ on category listing sheet Description: _____________________________________________ Value$ __________ H/W/J/C Line 2: ____________________________________________________________________Location: _____________________________________________________________________Line 2:_____________________________________________________________________Exempt: $____________________ Spouse: $_____________________Office Use: cite number on citation list: ________________Property type: [ ] Real Estate [ ] Personal-#___ on category listing sheet Description: ____________________________________________ Value$ __________ H/W/J/C Line 2:_____________________________________________________________________Location: _____________________________________________________________________Line 2:_____________________________________________________________________Exempt: $____________________ Spouse: $_____________________Office Use: cite number on citation list: ________________ CLAIMS WITH PRIORITY, Schedule E ATTACH A COPY OF YOUR MOST RECENT STATEMENT FOR EACH DEBT Creditor's Name: _____________________________________________________________ Address: _____________________________________________________________Line 2: _____________________________________________________________Line 3: _____________________________________________________________Account Number: ________________

 

Collection Agency

or Representative: ___________________________________________________________

Address: _____________________________________________________________

Line 2: _____________________________________________________________

Line 3: _____________________________________________________________

 

Type of Claim: [ ] Government [ ] Wages [ ] Employee Benefits [ ] Deposit

[ ] Farmers-Fishermen [ ] Alimony -Child-Supp

Claim: $_________________ Priority Portion: $_________________

Conditions: [ ] Contingent [ ] Disputed [ ] Unliquidated (Choose any)

 

Codebtor's Name: _____________________________________________________________

(Ex-spouse must include aliases)

Address: _____________________________________________________________

Line 2: _____________________________________________________________

Line 3: _____________________________________________________________

 

Reason for Claim: _____________________________________________________________

Line 2: _____________________________________________________________

Line 3: _____________________________________________________________

 

 

CLAIMS WITH PRIORITY, Schedule E

ATTACH A COPY OF YOUR MOST RECENT STATEMENT FOR EACH DEBT

 

Creditor's Name: _____________________________________________________________

Address: _____________________________________________________________

Line 2: _____________________________________________________________

Line 3: _____________________________________________________________

Account Number: ________________

 

Collection Agency

or Representative: ___________________________________________________________

Address: _____________________________________________________________

Line 2: _____________________________________________________________

Line 3: _____________________________________________________________

 

Type of Claim: [ ] Government [ ] Wages [ ] Employee Benefits [ ] Deposit

[ ] Farmers-Fishermen [ ] Alimony -Child-Supp

Claim: $_________________ Priority Portion: $_________________

Conditions: [ ] Contingent [ ] Disputed [ ] Unliquidated (Choose any)

 

Codebtor's Name: _____________________________________________________________

(Ex-spouse must include aliases)

Address: _____________________________________________________________

Line 2: _____________________________________________________________

Line 3: _____________________________________________________________

 

Reason for Claim: _____________________________________________________________

Line 2: _____________________________________________________________

Line 3: _____________________________________________________________

 

 

UNSECURED CLAIMS, Schedule F

ATTACH A COPY OF YOUR MOST RECENT STATEMENT FOR EACH DEBT

Creditor Name: ___________________________________________________________

Address: ___________________________________________________________

Line 2: ___________________________________________________________

Line 3: ___________________________________________________________

Account Number: __________________

 

Collection Agency

or Representative: ___________________________________________________________

Address: ___________________________________________________________

Line 2: ___________________________________________________________

Line 3: ___________________________________________________________

 

Amount of Claim: $_________________

When Incurred: __________________

Conditions: [ ] Contingent [ ]Disputed [ ] has Set-off [ ] Unliquidated

Codebtors' Name: ___________________________________________________________

Address: ___________________________________________________________

Line 2: ___________________________________________________________

Line 3: ___________________________________________________________

 

Reason for Claim: ___________________________________________________________

Line 2: ___________________________________________________________

Line 3: ___________________________________________________________

Intentions: [ ] Reaffirm [ ] None

Other: ____________________________________________________

 

 

UNSECURED CLAIMS, Schedule F

ATTACH A COPY OF YOUR MOST RECENT STATEMENT FOR EACH DEBT

Creditor Name: ___________________________________________________________

Address: ___________________________________________________________

Line 2: ___________________________________________________________

Line 3: ___________________________________________________________

Account Number: __________________

 

Collection Agency

or Representative: ___________________________________________________________

Address: ___________________________________________________________

Line 2: ___________________________________________________________

Line 3: ___________________________________________________________

 

Amount of Claim: $_________________

When Incurred: __________________

Conditions: [ ] Contingent [ ]Disputed [ ] has Set-off [ ] Unliquidated

Codebtors' Name: ___________________________________________________________

Address: ___________________________________________________________

Line 2: ___________________________________________________________

Line 3: ___________________________________________________________

 

Reason for Claim: ___________________________________________________________

Line 2: ___________________________________________________________

Line 3: ___________________________________________________________

Intentions: [ ] Reaffirm [ ] None

Other: ____________________________________________________

 

EXECUTORY CONTRACTS, Schedule G

(Leases except installment loans. Plus "Contracts in Progress".)

Other Party's Name: ___________________________________________________________

Address: ___________________________________________________________

Line 2: ___________________________________________________________

Line 3: ___________________________________________________________

Contract Type: [ ] Residential Lease [ ] Non-residential Lease

[ ] Vehicle Lease [ ] Sales Contract

[ ] Service Contract [ ] Land Contract

Government Contract - _______________________________________

Other: ______________________________________________________

Description: _____________________________________________________________

_____________________________________________________________

Terms: _____________________________________________________________

Buyout Option: _____________________________________________________________

Beginning Date: ____________________

Debtor's Interest: [ ] Lessor [ ] Lessee [ ] Purchaser [ ] Agent

[ ] Other:_________________

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Other Party's Name: ___________________________________________________________

Address: ___________________________________________________________

Line 2: ___________________________________________________________

Line 3: ___________________________________________________________

Contract Type: [ ] Residential Lease [ ] Non-residential Lease

[ ] Vehicle Lease [ ] Sales Contract

[ ] Service Contract [ ] Land Contract

Government Contract - _______________________________________

Other: ______________________________________________________

Description: _____________________________________________________________

_____________________________________________________________

Terms: _____________________________________________________________

Buyout Option: _____________________________________________________________

Beginning Date: ____________________

Debtor's Interest: [ ] Lessor [ ] Lessee [ ] Purchaser [ ] Agent

[ ] Other:_________________

 

BUDGET, Schedules I,J - DEBTOR & FAMILY INFORMATION

 

Marital Status: [ ] Married [ ] Single [ ] Divorced

[ ] Separated [ ] Separate Expenses

INDIVIDUAL DEBTOR SPOUSE

Occupation: _________________________ ____________________________

Employer: _________________________ ____________________________

How Long?: _________________________ ____________________________

Address: _________________________ ____________________________

Line 2: _________________________ ____________________________

 

 

 

 

 

 

 

 

DEPENDENTS

Name: Age: Relationship: Monthly $Amt + R/P/S/D*

______________________ ____ _____________ ______________ R/P/S/D

______________________ ____ _____________ ______________ R/P/S/D

______________________ ____ _____________ ______________ R/P/S/D

______________________ ____ _____________ ______________ R/P/S/D

______________________ ____ _____________ ______________ R/P/S/D

______________________ ____ _____________ ______________ R/P/S/D

______________________ ____ _____________ ______________ R/P/S/D

______________________ ____ _____________ ______________ R/P/S/D

* Payment Codes: R=receiving payments; P=making payments; S=spouse's dependent;

D=expenses (non-statutory payments) for dependents not living

at home

 

 

 

DEBTOR SPOUSE

Pay Period . . . . . . . . . . . . . . . (Circle One) Weekly Weekly

Bi-Weekly Bi-Weekly

2-Month 2-Month

Monthly Monthly

EARNING PER PAY PERIOD

Gross Pay per Pay Period. . . . . . . . . . . . . . . $ _________ _________

Estimated Overtime per Pay Period . . . . . . . . . . $ _________ _________

PAYROLL DEDUCTIONS PER PAY PERIOD

Payroll Taxes and Social Security . . . . . . . . . . $ _________ _________

Insurance . . . . . . . . . . . . . . . . . . . . . . $ _________ _________

Union Dues. . . . . . . . . . . . . . . . . . . . . . $ _________ _________

Other Deductions:____________________________________ $ _________ _________

_____________________________________________________ $ _________ _________

 

 

INCOME

Regular Income from Business, Profession or Farm. . . $ _________ _________

Income from Real Property . . . . . . . . . . . . . . $ _________ _________

Interest and Dividends. . . . . . . . . . . . . . . . $ _________ _________

Pension or Retirement Income. . . . . . . . . . . . . $ _________ _________

Alimony Received. . . . . . . . . . . . . . . . . . . $ _________ _________

Social Security/ Assistance -- Explain: ____________ $ _________ _________

____________________________________________________

Other Monthly Income: ______________________________ $ _________ _________

Line 2:_____________________________________________ $ _________ _________

Line 3:_____________________________________________ $ _________ _________

 

Itemize Income changes of more than 10% expected in the next 12 months:

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

 

 

BUDGET - MONTHLY EXPENSES

DEBTOR SPOUSE

Rent/Mortgage/Lot-Rental (T=tax/I=insurance included) $ _________ _________

Electricity and Heating Fuel. . . . . . . . . . . . . $ _________ _________

Water and Sewer . . . . . . . . . . . . . . . . . . . $ _________ _________

Telephone . . . . . . . . . . . . . . . . . . . . . . $ _________ _________

Other Utilities:_____________________________________ $ _________ _________

Line 2:______________________________________________ $ _________ _________

Line 3:______________________________________________ $ _________ _________

Home Maintenance. . . . . . . . . . . . . . . . . . . $ _________ _________

Food. . . . . . . . . . . . . . . . . . . . . . . . . $ _________ _________

Clothing. . . . . . . . . . . . . . . . . . . . . . . $ _________ _________

Laundry and Dry Cleaning. . . . . . . . . . . . . . . $ _________ _________

Medical and Dental Expenses . . . . . . . . . . . . . $ _________ _________

Transportation (not including car payment). . . . . . $ _________ _________

Recreation, Clubs & Entertain., Newspapers, Magazines $ _________ _________

Charitable Contributions. . . . . . . . . . . . . . . $ _________ _________

 

 

INSURANCE PAYMENTS

Homeowner's or Renter's Insurance . . . . . . . . . . $ _________ _________

Life Insurance. . . . . . . . . . . . . . . . . . . . $ _________ _________

Health Insurance. . . . . . . . . . . . . . . . . . . $ ________ _________

Auto Insurance. . . . . . . . . . . . . . . . . . . . $ _________ _________

Other Insurance:_____________________________________ $ _________ _________

Line 2:______________________________________________ $ _________ _________

Line 3:______________________________________________ $ _________ _________

Describe Taxes not included with mortgage or payroll: $ _________ _________

____________________________________________________

 

 

 

INSTALLMENT PAYMENTS – cont.

(Do not enter any installment payments that will be

made to the Chapter 13 trustee.)                      DEBTOR SPOUSE

 

Auto Installment Payments . . . . . . . . . . . . . . $ _________ _________

Other Installments:__________________________________ $ _________ _________

Line 2:______________________________________________ $ _________ _________

Alimony . . . . . . . . . . . . . . . . . . . . . . . $ _________ _________

Regular Expenses from Business, Profession or Farm. . $ _________ _________

Other Expenses:______________________________________ $ _________ _________

Line 2:______________________________________________ $ _________ _________

Line 3:______________________________________________ $ _________ _________

 

 

PETITION

Case Type: [ ] Individual [ ] Husband & Wife [ ] Partnership

[ ] Public Corp. [ ] Private Corp. [ ] Municipality

[ ] Other: _____________________________

Chapter: [ ] 7 [ ] 9 [ ] 11 [ ] 12 [ ] 13

Name: ___________________________________________________________

aka/dba 1: ___________________________________________________________

2: ___________________________________________________________

3: ___________________________________________________________

4: ___________________________________________________________

SS#/Tax ID#: ______________________________

Phone #: ______________________________

Street Address: ___________________________________________________________

City, State, & Zip: ___________________________________________________________

County: ______________________________

 

Mailing Address: ___________________________________________________________

Line 2: ___________________________________________________________

Line 3: ___________________________________________________________

 

 

Bus. Assets Adr.: ___________________________________________________________

Line 2: ___________________________________________________________

Line 3: ___________________________________________________________

BANKRUPTCIES DURING LAST 6 YEARS:

Where filed: ___________________________________________________________

Case Number: _____________________ Date filed: ________________________

PENDING RELATED BANKRUPTCY CASES:

Debtor Name: ___________________________________________________________

Case Number: _____________________ Date filed: ________________________

Relationship: ___________________________________________________________

District: __________________________ Judge: _________________________

SPOUSE INFORMATION

Name: ___________________________________________________________

aka/dba 1: ___________________________________________________________

2: ___________________________________________________________

3: ___________________________________________________________

4: ___________________________________________________________

SS#/Tax ID#: ______________________________

Street Address: ___________________________________________________________

City, State, & Zip: ___________________________________________________________

County: ______________________________

 

Mailing Address: ___________________________________________________________

Line 2: ___________________________________________________________

Line 3: ___________________________________________________________

 

 

PETITION Cont

 

Nature of Debts: [ ] Business [ ] Consumer

Type: [ ] Commodity Broker [ ] Construction [ ] Farming

[ ] Mfg-Mining [ ] Professional [ ] Railroad

[ ] Real Estate [ ] Retail-Wholesale [ ] Stock Broker

[ ] Transportation

[ ] Other:_______________________________________________________________

 

Describe Business: ______________________________________________________

Line 2: ______________________________________________________

Line 3: ______________________________________________________

Line 4: ______________________________________________________

Line 5: ______________________________________________________

Line 6: ______________________________________________________

 

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ESTIMATES: only needed for hurry-up filings

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K means thousands; Mil means millions

 

Assets: [ ] under $50,000 [ ] $50K-$99K [ ] $100K - $499K

[ ] $500K-$1 Mil [ ] $1 Mil–$10Mil [ ] $10Mil-$50 Mil

[ ] $50Mil-$100Mil [ ] $100 Million +

 

Debts: [ ] under $50,000 [ ] $50K-$99K [ ] $100K - $499K

[ ] $500K-$1 Mil [ ] $1 Mil–$10Mil [ ] $10Mil-$50 Mil

[ ] $50Mil-$100Mil [ ] $100 Million +

 

Any money to Unsecured: [ ] YES [ ] NO

 

Number of Creditors: [ ] 1-15 [ ] 16-49 [ ] 50-99

[ ] 100-199 [ ] 200-999 [ ] 1000+

 

Number of Employees: [ ] 0 [ ] 1-19 [ ] 20-99 [ ] 100-999 [ ] 1000+

 

Equity Security Holders: [ ] 0 [ ] 1-19 [ ] 20-99 [ ] 100-499 [ ] 500+

 

 

PETITION - DOCUMENT INFORMATION SCREEN

 

Company Signer Name: ________________________________________________________

Title: [ ] Authorized Agent [ ] Partner [ ] Officer

[ ] President [ ] Treasurer

[ ] Other: _____________________________________________

Signing Date: ______________________ Incorporation State: _________

 

Signing Attorney: ________________________________________________________

Other Listed Lawyers: ________________________________________________________

________________________________________________________

Attorney Fee: ____________

Amount Prepaid: ____________

Filing Fee: [ ] Attached [ ] Installments

 

Case Number: ____________

Ch. 13 Plan: [ ] NA(Chapter 7) [ ] File Later [ ]Attached - Date __________

Venue Basis: [ ] Debtor Here [ ] Related Case Pending Here

Financial Affairs: [ ] Consumer [ ] Business

Exhibit A: [ ] Yes(Corp Chap11) [ ] No(all other)

Exhibit B: [ ] Yes (Consumer debts) [ ] No (all other)

Use Exemptions?: [ ] Yes (Consumer debts) [ ] No (all other)

 

Trustee*: ________________________________________________________

Address: ________________________________________________________

Line 2: ________________________________________________________

Line 3: ________________________________________________________

 

Court District*: ______________________________________

Division*: ______________________________________

State*: ______________________________________

* only if different from pre-set

 

 

PETITION - UNUSUAL SOURCES SCREEN

(If the attorney fee etc comes from regular earnings, leave this sheet blank.)

 

1. Unusual Source of Prepayments

[ ] Source is debtor's earning (leave screen as "none other")

[ ] Enter Unusual Source: _____________________________________________________

 

 

2. Unusual Source of Next Payment

[ ] Source is debtor's earnings (leave screen as "none other")

[ ] Enter Unusual Source: _____________________________________________________

 

 

3. Transferred property to Attorney

[ ] None

[ ] Explain Transfer: _________________________________________________________

 

 

4. Unusual fee sharing

[ ] None

[ ] Explain: __________________________________________________________________

 

 

PETITION - EXHIBIT A (Chapter 11 only)

Estimates - for hurry up filings only Dollar Amount Number of Debts

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Secured Debts - Liquidated: $_______________ _______________

Contingent: $_______________ _______________

Unliquidated: $_______________ _______________

Unsecured - Liquidated: $_______________ _______________

Contingent: $_______________ _______________

Unliquidated: $_______________ _______________

 

 

SEC Registration No.: _____________________________

Number of Shares Number of Owners

Shares of Preferred: ________________ ________________

Shares of Common: ________________ ________________

 

 

Names of Persons who own or control 20% or more of debtor's shares:

1. ____________________________________________________________________________

2. ____________________________________________________________________________

3. ____________________________________________________________________________

4. ____________________________________________________________________________

5. ____________________________________________________________________________

 

 

Names of Companies in which debtor owns or controls more than 20% of ownership:

1. ____________________________________________________________________________

2. ____________________________________________________________________________

3. ____________________________________________________________________________

4. ____________________________________________________________________________

5. ____________________________________________________________________________

 

 

PETITION - CASE NOTES (Office use only)

 

 

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STATEMENT OF FINANCIAL AFFAIRS

Note: For brevity, various definitions and explanations have been omitted from

this questionnaire. For a printout of all the language, see full

version.

1. Income from Employment or Operation of Business.

List your gross income from employment, trade, profession, or your business. If a joint petition is filed, state income for each spouse separately. (Married debtors filing under chapter 12 or chapter 13 must state income of both spouses whether or not a joint petition is filed, unless the spouses are separated and a joint petition is not filed.)

 

DEBTOR'S INCOME SOURCE

Year to date: _______________________ ____________________________

Last year: _______________________ ____________________________

2 Years ago: _______________________ ____________________________

SPOUSE'S INCOME SOURCE

Year to date: _______________________ ____________________________

Last year: _______________________ ____________________________

2 Years Ago: _______________________ ____________________________

 

2. Income other than from Employment or Operation of Business.

List all income received by the debtor other than from employment, trade, profession, or operation of the debtor's business during the two years immediately preceding the commencement of this case. Give particulars.

If a joint petition is filed, state income for each spouse separately. (Married debtors filing under chapter 12 or chapter 13 must state income for each spouse whether or not a joint petition is filed, unless the spouses are separated and a joint petition is not filed.) .

DEBTOR'S INCOME SOURCE

Year to date: _______________________ ____________________________

Last year: _______________________ ____________________________

2 Years ago: _______________________ ____________________________

SPOUSE'S INCOME SOURCE

Year to date: _______________________ ____________________________

Last year: _______________________ ____________________________

2 Years Ago: _______________________ ____________________________

 

3. Payments to Creditors.

a. List all payments made during the last 90 days, on loans, installments

purchases or other debts, that add up to more than $600 for any one creditor. (Married debtors filing under chapter 12 or chapter 13 must include payments by either or both spouses whether or not a joint petition is filed, unless the spouses are separated and a joint petition is not filed.)

Creditor: __________________________________________

Address: __________________________________________

Line 2: __________________________________________

Amount paid: __________________________________________

Payment dates: __________________________________________

Amount owing: __________________________________________

b. List all payments during the last 12 months to or for the benefit of

creditors who are or were insiders. (Married debtors filing under chapter 12 or chapter 13 must include payments by either or both spouses whether or not a joint petition is filed, unless the spouses are separated and a joint petition is not filed.)

Creditor: __________________________________________

Address: __________________________________________

Line 2: __________________________________________

Amount paid: __________________________________________

Payment dates: __________________________________________

Amount owing: __________________________________________

4. Suits and Administrative Proceedings, Executions, Garnishments and Attachments.

a. List all suits and administrative proceedings to which the debtor is or was a party within one year immediately preceding the filing of this bankruptcy case. (Married debtors filing under chapter 12 or chapter 13 must include information concerning either or both spouses whether or not a joint petition is filed, unless the spouses are separated and a joint petition is not filed.)

Case title: __________________________________________

Case number: __________________________________________

Court and location: __________________________________________

Nature of proceeding: __________________________________________

Status or disposition

of case: __________________________________________

b. Describe all property that has been attached, garnished or seized under any legal or equitable process within one year immediately preceding the commencement of this case. (Married debtors filing under chapter 12 or chapter 13 must include information concerning property of either or both spouses whether or not a joint petition is filed, unless the spouses are separated and a joint petition is not filed.)

Beneficiary of

seizure: __________________________________________

Address: __________________________________________

Line 2: __________________________________________

Seizure date: __________________________________________

Property description: __________________________________________

Value: __________________________________________

 

5. Repossessions, Foreclosures and Returns.

List all property that has been repossessed by a creditor, sold at a

foreclosure sale, transferred through a deed in lieu of foreclosure or returned

to the seller, during the last 12 months. (Married debtors filing under chapter 12 or chapter 13 must include information concerning property of either or both spouses whether or not a joint petition is filed, unless the spouses are separated and a joint petition is not filed.)

Creditor/seller: __________________________________________

Address: __________________________________________

Line 2: __________________________________________

Property description: __________________________________________

Value: __________________________________________

 

6. Assignments and Receiverships.

a. Describe any assignment of property for the benefit of creditors

during the last 120 days. (Married debtors filing under chapter 12 or chapter 13 must include any assignment by either or both spouses whether or not a joint petition is filed, unless the spouses are separated and a joint petition is not filed.)

Assignee: __________________________________________

Address: __________________________________________

Line 2: __________________________________________

Date: __________________________________________

Terms: __________________________________________

 

 

b. List all property which has been in the hands of a custodian, receiver,

or court-appointed official during the last 12 months. (Married debtors filing under chapter 12 or chapter 13 must include any assignment by either or both spouses whether or not a joint petition is filed, unless the spouses are separated and a joint petition is not filed.)

 

Custodian: __________________________________________

Address: __________________________________________

Line 2: __________________________________________

Court: __________________________________________

Case title: __________________________________________

Case #: __________________________________________

Date of order: __________________________________________

Property description: __________________________________________

Value: __________________________________________

 

7. Gifts.

List all gifts or charitable contributions during the last 12 months except gifts to family members worth under $200 per individual, and except charitable contributions worth under $100 per recipient. (Married debtors filing under chapter 12 or chapter 13 must include gifts or contributions by either or both spouses whether or not a joint petition is filed, unless the spouses are separated and a joint petition is not filed.)

Recipient: __________________________________________

Address: __________________________________________

Line 2: __________________________________________

Relationship to

debtor: ________________________________________

Date of gift: __________________________________________

Description: __________________________________________

Value: __________________________________________

 

 

8. Losses.

List all losses from fire, theft, other casualty or gambling during

the last 12 months. (Married debtors filing under chapter 12 or chapter 13 must include losses by either or both spouses whether or not a joint petition is filed, unless the spouses are separated and a joint petition is not filed.)

Property: __________________________________________

Value: __________________________________________

Circumstances: __________________________________________

Insurance coverage: __________________________________________

Date of loss: __________________________________________

 

9. Payments Related to Debt Counseling or Bankruptcy.

List all payments made or property transferred by or for you during the

last 12 months to anyone including lawyers, for help with debt consolidation,

or with bankruptcy filing, including just typing the forms,

Payee: __________________________________________

Address: __________________________________________

Line 2: __________________________________________

Date of payment: __________________________________________

Payor: __________________________________________

Payment/Value: __________________________________________

10. Other Transfers.

List all other property transferred, either absolutely or as a security,

during the last 12 months, except as usual in your business or in your

financial affairs. (Married debtors filing under chapter 12 or chapter 13 must include transfers by either or both spouses whether or not a joint petition is filed, unless the spouses are separated and a joint petition is not filed.)

Transferee: __________________________________________

Relationship to debtor: __________________________________________

Date of transfer: __________________________________________

Property: __________________________________________

Value: __________________________________________

 

 

11. Closed Financial Accounts.

List all financial accounts in your name or held for your benefit, which

were closed, sold, or otherwise transferred during the last 12 months.

Include checking, savings, and other accounts, certificates of deposit and

other instruments; shares and share accounts held in banks, credit unions,

pension funds, cooperatives, associations, brokerage houses and other financial

institutions. (Married debtors filing under chapter 12 or chapter 13 must include information concerning accounts or instruments held by or for either or both spouses whether or not a joint petition is filed, unless the spouses are separated and a joint petition is not filed.)

 

Institution: __________________________________________

Address: __________________________________________

Line 2: __________________________________________

Type of account: __________________________________________

Account #: __________________________________________

Final balance: _______________ Closing Date: __________

12. Safe Deposit Boxes. List each safe deposit or other box or depository in which the debtor has or had securities, cash, or other valuables during the last 12 months. (Married debtors filing under chapter 12 or chapter 13 must include boxes or depositories of either or both spouses whether or not a joint petition is filed, unless the spouses are separated and a joint petition is not filed.)Institution:__________________________________________Address: __________________________________________Line 2:__________________________________________ Person with access: __________________________________________Address:__________________________________________ Line 2: __________________________________________Contents: __________________________________________ Surrender date: __________________________________________ 13. Setoffs. List all setoffs made by any creditor, including a bank, against a debt or deposit of the debtor, during the last 90 days. (Married debtors filing under chapter 12 or chapter 13 must include information concerning either or both spouses whether or not a joint petition is filed, unless the spouses are separated and a joint petition is not filed.)Creditor:__________________________________________Address:__________________________________________Line 2:__________________________________________Setoff date: __________________________________________Amount:__________________________________________ 14. Property Held for Another Person. List all property owned by another person that the debtor holds or controls. Owner:__________________________________________Address:__________________________________________Line 2:__________________________________________Property:__________________________________________Description:__________________________________________Value:__________________________________________Location:__________________________________________ 15. Prior Address of Debtor. If you have moved during the last 24 months, list all previous addresses. Address: __________________________________________Line 2:__________________________________________Name(s)used: __________________________________________Dates:__________________________________________Spouse's Address: ______________________Line 2: __________________________________________ Name(s) used: __________________________________________ Dates: __________________________________________ 16. Spouses and Former Spouses. If you currently reside or if during the last six years you have resided in a community property state, commonwealth, or territory (including Alaska, Arizona, California, Idaho, Louisiana, Nevada, New Mexico, Puerto Rico, Texas, Washington, or Wisconsin), list the name of your spouse or any former spouse who resides or resided with you in the community property state. Name of Spouse: __________________________________________Dates of residence with spouse in community property state or territory and name thereof:__________________________________________Name of Former Spouse: __________________________________________ Dates of residence with former spouse in community property state or territory and name thereof: __________________________________________ 17. Environmental Information. a. List the name and address of every site for which the debtor has 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: SITE NAME NAME AND ADDRESS DATE ENVIRON AND OF GOVERNMENTAL OF MENTAL ADDRESS UNIT NOTICE LAW ____________________ ________________ _________ ____________________________________________ _________ _________ b. List the name and address of every site for which the debtor provided notice 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. SITE NAME NAME AND ADDRESS DATE ENVIRON AND OF GOVERNMENTAL OF MENTAL ADDRESS UNIT NOTICE LAW ____________________ ________________ _________ ____________________________________________ _________ _________c. List all judicial or administrative proceedings, including settlements or orders, under any Environmental Law with respect to which the debtor is or was a party. Indicate the name and address of the governmental unit that is or was a party to the proceeding, and the docket number. NAME AND ADDRESS DOCKET NUMBER STATUS OR OF GOVERNMENTAL UNIT DISPOSITION ___________________ _________________ ______________ 18. Nature, Location and Name of Business. a. If the debtor is an individual, list the names, addresses, taxpayer identification numbers, nature of the businesses, and beginning and ending dates of all businesses in which the debtor was an officer, director, partner, or managing executive of a corporation, partnership, sole proprietorship, or was a self-employed professional within the six years immediately preceding the commencement of this case, or in which the debtor 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 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. Business Name: __________________________________________Taxpayer I.D. Number: __________________________________________Address: __________________________________________Line 2:__________________________________________Nature of business: __________________________________________ Beginning and Ending Dates: Start Date: ______________ End Date: ______________b. Identify any business listed above, that is single asset real estate as defined in 11 U.S.C. § 101. Business Name: __________________________________________Address: __________________________________________line 2: __________________________________________ ********BUSINESS OWNERS ONLY ANSWER 19-25******* Note: Questions 19 to 25 can be left blank by persons who have not been in business (or an insider in a business) during the last 2 years. 19. Books, records and financial statements. a. List all bookkeepers and accountants who within the two years immediately preceding the filing of this bankruptcy case kept or supervised keeping of books of account and records of the debtor. Name:__________________________________________Address:__________________________________________Line 2: __________________________________________Dates Services Rendered: __________________________________________b. 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. Name:__________________________________________Address:__________________________________________Line 2: __________________________________________Dates Services Rendered: __________________________________________c. List all firms or individuals who at the time of the commencement of this case were in possession of the books of account and records of the debtor. If any of the books of account and records are not available, explain. Name:__________________________________________Address:__________________________________________Line 2:__________________________________________Unavailable records: __________________________________________d. List all financial institutions, creditors and other parties, including mercantile and trade agencies, to whom a financial statement was issued within two years immediately preceding the commencement of this case by the debtor. Name:__________________________________________Address:__________________________________________Line 2:__________________________________________Date issued: __________________________________________ 20. Inventories. a. 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. Last inventory date: __________________________________________Inventory supervisor: __________________________________________Dollar Amount of Inventory:__________________________________________Valuation basis: Cost / Market / Other ____________________Prior inventory date: __________________________________________Inventory supervisor: __________________________________________Dollar Amount of Inventory: __________________________________________Valuation basis: Cost / Market / Other ____________________b. List the name and address of the person having possession of the records of each of the two inventories reported in a., above. Last inventory date: __________________________________________ Custodian of records: __________________________________________ Address:__________________________________________Line 2:__________________________________________Prior inventory date: __________________________________________ Custodian of records: __________________________________________ Address: __________________________________________ Line 2:__________________________________________ 21. Current Partners, Officers, Directors and Shareholders. a. If the debtor is a partnership, list the nature and percentage of partnership interest of each member of the partnership. Name of Partner: __________________________________________Address:__________________________________________Line 2:__________________________________________Nature of interest: __________________________________________Percentage ownership: __________________________________________b. If the debtor is corporation, list all officers and directors of the corporation, and each stockholder who directly or indirectly owns, controls, or holds 5 percent or more of the voting securities of the corporation. Name:__________________________________________Address:__________________________________________Line 2: __________________________________________Title:__________________________________________Nature and percentage of stock ownership: __________________________________________ 22. Former Partners, Officers, Directors and Shareholders. a. If the debtor is a partnership, list each member who withdrew from the partnership within one year immediately preceding the commencement of this case. Name:__________________________________________Address:__________________________________________Line 2:__________________________________________Title:__________________________________________Date of withdrawal: __________________________________________b. If the debtor is a corporation, list all officers, or directors whose relationship with the corporation terminated within one year immediately preceding the commencement of this case. Name:__________________________________________Address:__________________________________________Line 2:__________________________________________Title: __________________________________________Date of termination: __________________________________________23. Withdrawals from a Partnership or Distributions by a Corporation. If the debtor is a partnership or corporation, list all withdrawals or credited or given to an insider, including compensation in any form, bonuses, loans, stock redemptions, options exercised and any other prerequisite during one year immediately preceding the commencement of this case. Recipient's name: __________________________________________Address: __________________________________________Line 2:__________________________________________Relationship to debtor: __________________________________________ Date of withdrawal: __________________________________________Purpose of withdrawal: __________________________________________ Amount of money or value of property: __________________________________________24. Tax Consolidation Group. If the debtor is a corporation, list the name and federal taxpayer identification number of the parent corporation of any consolidated group for tax purposes of which the debtor has been a member at any time within the six-year period immediately preceding the commencement of the case. Name of Parent Corporation: __________________________________________Taxpayer I.D. Number: __________________________________________ 25. Pension Funds. If the debtor is not an individual, 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. Name of Pension Fund: __________________________________________Taxpayer I.D. Number: __________________________________________THE 20 LARGEST UNSECURED CLAIMS CREDITOR'S CONTACT: Enter address only if different from Creditor's. Creditor: ______________________________________Contact: ______________________________________ Phone #: __________________>Address:___________________________________________________________________Line 2: ___________________________________________________________________Line 3:___________________________________________________________________Creditor:______________________________________Contact: ______________________________________ Phone #: __________________Address:___________________________________________________________________Line 2: ___________________________________________________________________Line 3:___________________________________________________________________Creditor: ______________________________________Contact:______________________________________ Phone #: __________________Address: ___________________________________________________________________Line 2: ___________________________________________________________________Line 3: ___________________________________________________________________Creditor: ______________________________________Contact: ______________________________________ Phone #: __________________Address: ___________________________________________________________________Line 2: ___________________________________________________________________Line 3: ___________________________________________________________________ EQUITY SECURITY HOLDERS Name: __________________________________________________________Address: __________________________________________________________Line 2:__________________________________________________________Line 3:__________________________________________________________Number of Shares: _______________Stock Class Kind of Interest: __________________________________________________________Number of Shares: _______________Class&; Interest: __