Type of Bankruptcy Sought:
Chapter 7 (Debt elimination) Yes/No
Chapter 13 (Debt consolidation) Yes/No
Other Chapter? ___________________
Are you currently on active duty in the uniformed services? Yes/No
Income and Means Test:
Disabled Veteran
1. Are you a Disabled Veteran whose debt was incurred during active duty or while performing homeland security activity? Yes/no
Reservist or National Guard Member
2. Are you a Reservist or National Guard member and called to active duty after September 11, 2001 for a period of at least 90 days? Yes/no
a. If yes, did you remain on active duty? Yes/ no
b. If yes, were you released from active duty less than 450 days before bankruptcy was filed? Yes/ No
i. If yes, list the date released from active duty________________
3. Are you a Reservist or National Guard member performing homeland defense activity for a period at least 90 days? Yes/No
a. Are you still performing homeland defense? Yes/No
b. Did you perform homeland defense terminating less than 540 days before bankruptcy case was filed? Yes/No
i. If yes, list the date of termination of homeland defense __________________
Non-Consumer Debts
4. Are your debts mostly Non-Consumer Debts (see list below)? Yes/No
Non-Consumer Debts include: Most tax debts; business or commercial debts; Insurance liabilities; Mortgages for investment or commercial purposes.
Consumer Debts include: personal, family or household debts; mortgage on your home; medical bills; student loans; credit cards; personal loans; car loans; loans for household goods.
Budget and Credit Counseling
5. Did you receive budget and credit counseling within the last 180 days? Yes/no
a. If yes, list name of agency and attach copy of certificate_______________________
b. If no, are urgent circumstances involved that would allow a waiver? (Realize that courts usually deny requests for waiver.) Yes/no
Interview Questions for Means Test
6. How many people in your household (not number of dependents- can include parents, grandparents, friends, or other relatives)? _____
7. Are you married? Yes/No
a. If yes, will you be filing jointly with your spouse? Yes/No
b. If yes, are you and your spouse legally separated? Yes/No
c. If yes, do you and your spouse live in separate households? Yes/No
8. List Dependents’ name, age, and relationship:
Your Income
9. Your occupation? _____________________________________
10. How long have you been employed? ________________
11. Your employer’s name? _________________________________________
12. Your employer’s address? __________________________________________
13. Your age? ___________
14. Your gross wages, salary and commissions from all jobs (Monthly income)? _____________
15. Your overtime wages per month? ____________________
16. Your taxes and social security payroll deductions? ____________________
17. Your insurance payroll deductions?__________________________
18. Your union dues and uniforms payroll deductions? ___________________________
19. Other payroll deductions? (specify) __________________________________________
20. Your gross receipts from operation of business or farm or profession? ______________
21. Your ordinary and necessary expense for operation of business, farm or profession? ___________
22. Your Gross receipts from real estate? ___________________
23. Your ordinary and necessary expense for operation of real estate? ________________
24. Your net income from real estate? ________________________________
25. Your interest and dividends? _____________________
26. Alimony or support you receive?_____________________________
27. Social Security or other government assistance you receive (specify)? _________________
28. Your income from pension or retirement? _________________________
29. Your unemployment? ____________________________
30. Your other income? _____________________________
Your Spouse’s Income
31. If married:
a. Your spouse’s occupation? ____________________________________
b. How Long Spouse has been employed? _____________
c. Your spouse’s employer’s name? ______________________________________
d. Your spouse’s employer’s address? _____________________________________
e. Your spouse’s age? _____________
f. Spouse’s gross wages, salary, and commissions from all jobs (monthly) _________________
g. Spouse’s overtime wages per month? _________________________
h. Spouse’s taxes and social security payroll deductions? ___________________
i. Spouse’s insurance payroll deductions? ___________________________
j. Spouse’s union dues and uniform payroll deductions? _________________________
k.. Spouse’s other deductions (specify)? ______________________________________
l. Spouse’s gross receipts from operation of business or farm or profession? _________
m. Spouse’s ordinary and necessary expenses for operation of business, farm or profession? ________________________
n. Spouse’s gross receipts from real estate? ________________
o. Spouse’s ordinary and necessary expense for operation of real estate? _______________
p. Spouse’s net income from real estate? _________________________
q. Spouse’s interest and dividends? ______________________________
r. Spouse’s alimony or support received? ___________________________
s. Spouse’s social security or other government assistance (specify)? ________________
t. Spouse’s income from pension or retirement? ___________________________
u. Spouse’s unemployment? ____________________________________
v. Spouse’s other income (specify)? _____________________________
32. Describe any changes of more than 10% in any of the above income categories that you anticipate to occur within the year following your bankruptcy. _________________________
Expenses- Do not include payments for debts that will be discharged
Home
33. Monthly Rent (including lot rent for mobile home) __________________
a. Are real estate taxes included? Yes/no
b. Is property insurance included? Yes/ No
34. Are you planning to continue to make payments on your mortgage after bankruptcy? Yes/no
35. Mortgage Company Name_______________________
36. Property Description________________________________________________
37. Monthly payment __________________
38. Total amount in missed or unpaid back payments ____________________
39. Total amount in arrears _________________________
Utilities (Monthly)
40. Electric and heating fuel ____________
41. Water and sewer _______________
42. Telecommunication (telephone, cell phone, pager, call waiting, caller id, internet) ________
43. Other utility (specify) __________________
Other
44. Home maintenance (repair and upkeep) _______________
45. Food ________________
46. Clothing ________________
47. Laundry and dry cleaning _____________________
48. Health care: medical and dental expense _________________________
49. Transportation (not car payment) _________________________
50. Recreation including clubs and entertainment, newspapers, magazines ____________________
51. Charitable contributions _____________
Insurance (Monthly)
52. Homeowner’s or renter’s insurance ____________
53. Term life insurance ________________
54. Whole life insurance _________________
55. Disability insurance ___________________
56. Health insurance _____________________
57. Auto insurance _____________________
58. Other insurance ______________________
Taxes
59. Real estate taxes not included in mortgage ____________
60. Other taxes not deducted from wages ________________
Car Payments (for cars keeping after bankruptcy)
61. Name of auto loan company __________________________
62. Year and make of car ____________________________
63. Monthly payment _____________________________
64. Total in missed or unpaid back payments _______________
65. Does the payment include taxes or insurance? Yes/no
Other Future Payments (Don’t include debts discharged in bankruptcy)
66. Name of creditor ________________________
67. Description of property_____________________
68. Monthly payment __________________________
69. Total amount in missed or unpaid payments ___________________
70. Does the payment include taxes or insurance? Yes/No
Other Monthly Expenses
71. Child care (not education expenses) ____________
72. Alimony, maintenance and support paid to others __________
73. Payments for additional dependents not living at your home ______________
74. Health savings account expenses ___________________
75. Amounts paid for care and support of elderly, chronically ill, or disabled members of family or household ___________________________
76. Amount you pay to maintain safety of family under Family Violence Prevention Act or other federal law _______________________
77. Amount you pay for education of your children under 18 for elementary and secondary school (max can be $137.50 per child) _______________________
78. Education expense required for employment or for physically or mentally challenged dependent child __________________________
79. Other expenses (specify) _____________________
80. Total of all expenses listed _____________
81. Total of all income on income pages ____________
82. Excess income (Income minus expenses) _______________
83. If married, what amounts of spouse’s monthly income is not regularly contributed to household expenses? (Include payments made for: child and spousal support of others, care or maintenance of other persons not your dependents, spouse’s own tax obligations, spouse’s own medical bills, spouse’s own car payments, spouse’s own separate real estate, spouse’s own judgments, spouse’s own education) ______________________________
Prior Bankruptcy
84. Prior Bankruptcy Case Filed in the Last 8 years? Yes/ no
a. If yes, location filed? ____________________
b. If yes, Case number? _________________________
c. If yes, date? _____________________________
85. Is there a pending bankruptcy case filed by your spouse, partner or affiliate? Yes/No
a. If yes, Name of Debtor________________________
b. If yes, Location ______________________________
c. If yes, Date _______________________________
d. If yes, Case Number _________________________
e. If yes, relation _____________________________
f. If yes, Judge ________________________________
86. Name and Address of co-Debtors _________________________________________
Your Past Income from Employment or Business
87. Your current Income From January 1st to today __________________ Year ____________ Source __________________
88. Your last year’s income __________________________________ Year ___________ Source ________________
89. Your income Year before Last _____________________________ Year ___________ Source _________________
Your Past Income from Other Sources excluding Employment or Business
90. Your Current income from January 1st to today _________________ Year ___________
Source ____________________
91. Your Last year’s income _____________________________ Year ____________ Source ________________________
92. Your Income Year Before Last _____________________________ Year ____________ Source _______________________
Your Spouse’s Income (If filing jointly)
Past Income from Employment or Business
93. Spouse’s current income from January 1st to today ___________________ Year _______ Source _____________________________
94. Spouse’s last year’s income ____________________________ Year ___________ Source ____________________________
95. Spouse’s income year before last _______________________ Year _____________ Source ___________________________
Past Income from Other Sources excluding employment or business
96. Spouse’s current income from January 1st to today ____________________ Year ________ Source __________________________
97. Spouse’s last year income __________________________ Year ______________ Source ___________________
98. Spouse’s income year before last ___________________ Year ________________ Source _____________________
Miscellaneous Questions
99. List all payments on loans, installment purchases of goods or services, and other debts, aggregating more than $600 to any creditor, made within 90 days immediately preceding the commencement of this case. _________________________________
100. Debtor whose debts are not primarily consumer debts: List all payments $5000 or more made within 90 days immediately preceding the commencement of this case to any one creditor. _____________________________________________________
101. List all payments made within one year immediately preceding the commencement of this case to or for the benefit of creditors who are or were insiders. (only for corporations) _______________________________________
102. 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. ___________________________________________________________
103. 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. ____________________________________________________________
104. 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, within one year immediately preceding the commencement of this case. _______________________________________________________________
105. Describe any assignment of property for the benefit of creditors made within 120 days immediately preceding the commencement of this case. (Only for corporations) ________________________________________________________________
106. 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. (Only for corporations) _________________________________________________________________
107. List all gifts or charitable contributions made within one year immediately preceding the commencement of this case except ordinary and usual gifts to family members aggregating less than $200 in value per individual family member and charitable contributions aggregating less than $100 per recipient. _________________________________________________________
108. List all losses from fire, theft, other casualty or gambling within one year immediately preceding the commencement of this case or since the commencement of this case. ________________________________________________________________
109. List all payments made or property transferred by or on behalf of the debtor to any persons, including attorneys, for consultation concerning debt consolidation, relief under the bankruptcy law or preparation of a petition in bankruptcy within one year immediately preceding the commencement of this case. _________________________________________________________________
110. List all other property, other than property transferred in the ordinary course of the business or financial affairs of the debtor, transferred either absolutely or as security within one year immediately preceding the commencement of this case. (only for corporations) ________________________________________________________________________
111. List all financial accounts and instruments held in the name of the debtor or for the benefit of the debtor which were closed, sold, or otherwise transferred within one year immediately preceding the commencement of this case. Include checking, savings, or toerh financial accounts, certificates of deposit, or other instruments; shares and share accounts held in banks, credit unions, pension funds, cooperatives, associations, brokerage houses and other financial institutions. ____________________________________________________
112. List each safe deposit or other box or depository in which the debtor has or had securities, cash, or other valuables within one year immediately preceding the commencement of this case. ____________________________________________________________
113. List all setoffs made by any creditor, including a bank, against a debt or deposit of the debtor within 90 days preceding the commencement of this case. (Only for corporations) __________________________________________________________________________
114. List all property owned by another person that the debtor holds or controls. __________________________________________________________________
115. If the debtor has moved within the two years immediately preceding the commencement of this case, list all premises which the debtor occupied during that period and vacated prior to the commencement of this case. (address and dates of occupancy) ____________________________________________________________________
116. If the debtor resides or resided in a community property state, commonwealth, or territory (including Alaska, California, Idaho, Louisiana, Nevada, New Mexico, Puerto Rico, Texas, Washington, or Wisconsin) within the six-year period immediately preceding the commencement of the case, identify the name of the debtor’s spouse and of any former spouse who resides or resided with the debtor in the community property state. __________________________________________________________________________
117. 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. (only for corporations) __________________________________________________________________________
118. List the name and address of every site for which the debtor 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. (only for corporations). _____________________________________________________________________________
119. 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. (only for corporations). ___________________________________________________
120. 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% or more of the voting or equity securities within the six years immediately preceding the commencement of this case.
121. Identify any business listed in response to the above question that is a “single asset real estate” as defined in 11 U.S.C. § 101. (only for corporations). _________________________________________________________________
122. Is the debtor a corporation or partnership or an individual debtor who is or has been, within the 6 years immediately preceding the commencement of this case, any of the following: an officer, director, managing executive, or owner of more than 5% of the voting or equity securities of a corporation; a partner, other than a limited partner, or a partnership; a sole proprietor or otherwise self employed? Yes/ No If yes, answer the subparts below.
a. List all bookkeepers and accountants who within the two years immediately preceding the filing of this bankruptcy case kept or supervised the keeping of books of account and records of the debtor. (only for corporations) ______________________________________________________________
b. List all firms or individuals who within the 2 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. (only for corporations). __________________________________________________________________
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. (only for corporations). _________________________________________________________________
d. List all financial institutions, creditors and other parties, including mercantile and trade agencies, to whom a financial statement was issued within the 2 years immediately preceding the commencement of this case by the debtor. (Only for corporations). ________________________________________________________________
e. 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. (only for corporations) _______________________________________________________________________
f. List the name and address of the person having possession of the records of each of the two inventories reported above. (only for corporations). ______________________________________________________________________
g. If the debtor is a partnership, list the nature and percentage of partnership interest of each member of the partnership (only for partnerships). _______________________________________________________________________
h. If the debtor is a 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 or equity sercurities of the corporation. (only for corporations). ____________________________________________________________________
i. If the debtor is a partnership, list each member who withdrew from the partnership within one year immediately preceding the commencement of this case. (only for partnerships). ______________________________________________________
j. 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. (only for corporations). _________________________________________
k. If the debtor 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. __________________________________
l. 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 6-year period immediately preceding the commencement of the case. ___________________________________________
m. 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 6-year period immediately preceding the commencement of the case. ____________________________________________
123. Creditors. List on separate sheet: name of creditor, address, phone number, interest rate, balance, monthly payment, months to repay, whether secured or not, type of debt
124. Court Filing Fee. Are you able to pay the court filing fee? Yes/No
a. If no, enter a reason for a fee waiver _____________________________________________________________________
b. In some cases, the court may allow payments of the court fee. I do not recommend this as you must justify this in front of a judge, and if you miss a payment, your case is dismissed. Would you like to try installment payments? Yes/No
Eviction
125. Are you in the process of eviction and your landlord has gotten a judgment ordering you to vacate residential property? Yes/No
a. If yes, Name of Landlord _______________________________
b. If yes, Address of Landlord ______________________________
c. To stop the eviction, you must give the court a deposit equal to one month’s rent at the time of filing or claim that under the law you are permitted to pay the money owed
Reaffirmation
126. Would you like to reaffirm any of your debts? Yes/no
a. If yes, list the amount of debt you would like to reaffirm ________________
b. If yes, list fees and costs accrued relating to this debt ___________________
c. If yes, list the total amount agreed to reaffirm _________________________
d. If yes, list the name of the creditor __________________________________
e. If yes, list the address of the creditor _________________________________
_________________________________________
Disclaimers: Information on this web site can not be construed as legal advice, and you are advised to seek legal counsel and not rely on this or any other website. Use of this web site does not create an attorney/client relationship and should not be viewed as creating such a relationship.
The determination of the need for legal services and the choice of a lawyer are extremely important decisions and should not be based solely upon advertisements or self-proclaimed expertise.
A description or indication of limitation of practice does not mean that any agency or board has certified such lawyer as a specialist or expert in an indicated field of law practice nor does it mean that such lawyer is necessarily any more expert or competent than any other lawyer. All potential clients are urged to make their own independent investigation and evaluation of any lawyer being considered.
"We are a Debt Relief Agency. We Help People File for Bankruptcy Under the Bankruptcy Code."
Contingent fee rates are subject to rule 32:1.5(c) and (d). Percentages are computed after deduction of costs and the public is advised that, in the event of an adverse verdict or decision, the contingent fee litigant could be liable for court costs, expenses of investigation, expenses of medical examinations, and costs of obtaining and presenting evidence. Contingent fee agreements are not available for criminal law cases and most family law cases.
In the event a lawyer’s communication seeks to advise the client of litigation, the client is advised that the filing of a claim or suit solely to coerce a settlement or to harass another could be illegal and could render the person so filing liable for malicious prosecution or abuse of process.
IRS Circular 230 Disclosure: To ensure compliance with requirements imposed by the U.S. Internal Revenue Service, we inform you that any tax advice contained on this website is not intended or written to be used, and cannot be used, for the purpose of (1) avoiding tax-related or other penalties under the U.S. Internal Revenue Code, or (2) promoting, marketing or recommending to another party any tax-related matter addressed herein.