WilkeyLaw - Bankruptcy - Financial Questionaire

Name:

Social Security Number:

Home Phone:

Work Phone:

E-Mail Address:

Other Names Used in the past 6 years (maiden name, former married name, nickname, etc.):

Address:

Zip Code:

List any other addresses used in past two years:

Present Marital Status

Married	Divorced
Single	Widowed

List your dependents including name, age and relationship:

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Occupation:
How Long:
Employer:
Employer's Address:

Spouse's Occupation:
How Long:
Spouse's Employer:
Employer's Address:
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Have you been in business in the past 6 years?ـ
Have you received other money, e.g. insurance, AFDC, etc in the past two years? If yes, please explain:
Have you closed a bank account in the past year? If yes, identify the bank, type of account, date closed and amount withdrawn:
Do you have a safety deposit box? If yes, describe the contents:
Do you have your financial records? If not, who has possession of them:
Have you anything that belongs to someone else? If yes, describe what it is and who owns it:
Have you ever filed bankruptcy before? If yes, state where, when, and case number:
Did you consolidate any bills in the past 6 months? If yes, state what bills were paid, who loaned you the money and how much was borrowed:
Are you now or were you involved in any lawsuit in the past year? If yes, bring a Court paper with you.
Have you been garnished or property attached or taken from you by a Court in the past 4 months? If yes, bring a Court paper with you.
In the past 90 days, have you paid a total of $600 or more to any unsecured creditor (that is, a creditor who does not have a lien)? If yes, name the creditor and amount paid:
Have you sold, transferred, or given away any property in the past year? If yes, describe the property, who received it and how much (if any) you received for it:
Has any property been repossessed or returned to a creditor in the past year? If yes, describe the property, identify the creditor and when it was repossessed/returned:
Has you lost anything in a fire or by theft or gambling in the past year? If yes, describe the property, its value, how it was lost, and if insurance covered it:
Did you see another attorney in the past year? If yes, name the attorney:
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Taxes You Owe
Internal Revenue Service: Include amount owed, type of tax and tax period:
State: Include amount owed, type of tax and tax period:
Other: Include all amounts owed, type of tax and tax period:
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DEBTS
Creditors With Collateral, Liens, Mortgages, and Security Interests

Name:
Address, zip code:
Amount owed (Payoff):
Collateral and value:
Monthly payment:

Name:
Address, zip code:
Amount owed (Payoff):
Collateral and value:
Monthly payment:

Name:
Address, zip code:
Amount owed (Payoff):
Collateral and value:
Monthly payment:

Other Secured Debts:

DO NOT FORGET TO LIST THE ADDRESS
AND ZIP CODE OF EACH CREDITOR

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DEBTS
OTHER CREDITORS
PLEASE LIST ANY OTHER CREDITORS, INCLUDING RELATIVES AND PEOPLE YOU ARE GOING TO PAY BACK. INCLUDE THE COMPLETE ADDRESS AND ZIP CODE.

NOTE: If a debt has been turned over for collection to a collection agency or attorney, give the complete name, address, and zip code of the creditor and the complete name, address, and zip code of the collection agency or attorney.

Name:
Address, zip code:
Amount owed (Payoff):

Name:
Address, zip code:
Amount owed (Payoff):

Name:
Address, zip code:
Amount owed (Payoff):

DO NOT FORGET TO LIST THE ADDRESS
AND ZIP CODE OF EACH CREDITOR

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YOUR PROPERTY You must give a value for all of your property. Please list as the value the amount that you believe your property would sell for today in its present condition.
Real Property (include your home, farm, mobile home, cemetary plot and any other real estate) Description and value:
Cash on hand Checking account bank and amount:
Cash on hand Savings Account bank and amount:
Other bank accounts and amount:
Landlord deposit and amount:
Household goods (list item and amount individually): couch, chairs, lamps, end and coffee tables, pictures, televisions, vcr, dinette set, cabinets, first bedroom set, 2nd bedroom set, 3rd bedroom set, dishwasher, microwave, stove, refrigerator, freezer, washer, dryer, lawnmower, other yard tools and any other items.
Total value of household goods:
Collections (coin, stamp, baseball cards, etc.) Description and value:
Vehicles (automobiles, trucks, trailers, other vehicles) Description and value:
Other Motorized Vehicles (boats, motors, accessories) Description and value:
Livestock, Poultry, Other Animals Description and value:
Farming Implements/Supplies Description and value:
Office Equipment, Furnishings, Supplies Description and value:
Business Equipment, Machinery, Supplies Description and value:
Inventory For Sale Description and value:
All other Personal Property Description and value:
Patents, Copyrights, Franchises, etc. Description and value:
Bonds and Notes Description and value:
Debts people owe you Description and value:
Claims you have against other people, e.g., accident or malpractice claims Description and value:
Insurance and annuity policies Description and value:
Stocks and Ownership interests in businesses Description and value:
Retirement Accounts Description and value:
All other Property Description and value:
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YOUR INCOME

Year to date earnings:

Do you receive your paycheck:

Weekly	Bi-Weekly
Twice/Month	Monthly
Other

Average Gross Pay (before taxes and other deductions) per pay period:

Payroll deductions per pay period:

Total take home pay per pay period: (Please bring your last pay stub)

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SPOUSE'S INCOME

Year to date earnings:

Does your spouse receive his/her paycheck:

Weekly	Bi-Weekly
Twice/Month	Monthly
Other

Average Gross Pay per pay period: (before taxes and other deductions)

Payroll deductions per pay period:

Total take home pay per pay period: (Please bring spouse's last pay stub)

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OTHER INCOME
Child Support/Alimony amount:
Pension/Retirement amount:
Social Security amount:
Business Income amount:
Other Income If you have business income, please provide a statement of your average monthly revenue and expenses either on a separate statement or in addition to this form.
Any other and amount:
Total Estimated Monthly Income:
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YOUR MONTHLY HOUSEHOLD EXPENSES
Rent or Mortgage Payment :
(also list real estate taxes and property inisurance if not included in rent or mortgage figure)
Utilities
- Electricity/Gas:
- Water/Sewer:
- Telephone:
- Cable:
- Other utilities:
Home Maintenance:
Food:
Clothing:
Laundry/Dry Cleaning:
Medical/Dental/Health Care:
Recreation:
Transportation:
(gas and maintenance but not car payaments)
Auto Insurance (mo. avg.):
(not deducted from wages)
Life Insurance (mo. avg.):
Health Insurance (mo. avg.):
Homeowner Insurance (mo. avg.):
Other Insurance (mo. avg.):
Taxes:
(not deducted from wages or included in home loan)
Child Support or Alimony:
Installment payments:
Other Expenses:
Other Expenses:
Total Monthly Expenses:
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Comments: Please include any info you did not have room for elsewhere in this form
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