INFORMATION NEEDED FOR BANKRUPTCY
PERSONAL:
Full Name (no initials)-

(all other names used in last 8 years)-
address-			         any other addresses used in past 3 years



phone number-
Social Security #-
occupation (title)-
Employer-
Employer’s address-



work phone #-
work schedule-
employed there since-
monthly income before deductions (gross)-$
monthly income after deductions (net)-$
marital status -
Children’s/Dependent’s names and dates of birth-


FINANCIAL:     # of dependents claimed:

paid every-  [  ] week   [  ] 2 weeks   [  ] month    [  ] other
taxes taken out: (per month):
Fed. -
State-
FICA-
other deductions-

Other regular monthly income-

Housing Expenses per month:

rent/mortgage-$
utilities (gas, water, electric, phone, cable)-$

Transportation Expenses per month:

Car payment-$
insurance-$
maintenance-$
gas/oil-$
Personal Expenses per month:  (Your Best Guess / Averages are Fine)
		           	
Food…………………….$
Clothes……………….…$
Medical and dental….…..$
Laundry/cleaning……….$
Personal articles………...$
Recreation……………....$
School (include food)…..$
Household………………$
Bus……………………...$
Childcare………………..$
Travel………………....…$
Gifts……………………..$
other (                      )…....$

How much money have you grossed this year- $  		         	source-

How much money did you gross in 2011- $				source-

How much money did you gross in 2010- $				source-
					
Assets:
Credit Union Accounts- (branch, balance, who’s name is it in?)



Checking and Savings Accounts-(branch, balance, who’s name?)



Stocks, Bonds, CD’s: (company, type, Title, date acquired, value)


Cars, Trucks, Motorcycles, Boats, Campers:
year      make          Title     Current market value     Debt owed on
       $			           $		


Real Property:
address                fee/lease     date acquired    cost       value     debt owed




Retirement/ Pension/ Profit Sharing accounts:
company        type       years in      benefits payable when        vested value


What is the Estimated Current Value of all of your:

Furniture and Appliances- $

Clothes- $

Books/Art/Records- $

Guns/Cameras- $

Jewelry- $


List any Property held in trust or by third persons-


Do you own a safe deposit box?    Yes     No


List all closed bank accounts (w/in past year) and balance and date of closing-



Are You part of any leases or continuing contracts? (give particulars)  Yes    No


List any property secured as collateral for a debt (car, home, computer, etc.)-



List names/addresses of any co-debtors (not listed on the bills)



Has anything been repossessed in the past year?  Yes      No 

Have you ever had to file for Bankruptcy before?  Yes     No

Give particulars of any pending lawsuits of any nature-