CREDIT COUNSELING PERSONAL WORK SHEETS
The attached forms are designed to gather together in one place, in an easily managed format, all the information necessary to make possible the best advice from an attorney regarding troubled financial affairs.
The Law Offices of Ken McCartney, P.C., may be (courts are debating the issue) a federally recognized Debt Relief Agency because we help assisted persons file for bankruptcy protection.
Your information format may vary from that of others. This set of worksheets is designed for use by individuals or husbands and wives. If you have a business involved, a different set of worksheets is required. The attachment is the format that most nearly fits your situation.
This Package Contains:
1. Budget
2. General Questions About You
3. Property Listing Sheets
4. Debt Listing Sheets
5. Appendix A (Disclosures, Document Request, List of Approved Credit Counseling Agencies)
It is not necessary to type these forms. PLEASE PRINT OR TYPE. The information accumulated on these forms can be translated very easily to the pleadings necessary when bankruptcy is filed, if they are properly prepared. If bankruptcy is not a realistic alternative, these forms make it possible to make that decision.
Most, but not all, clients can fill these forms out quickly. If you feel you would benefit from assistance in completing these forms, you may call our office nearest you and make an appointment with an administrative assistant who can work with you. This should only be done if bankruptcy or some other attorney related service will definitely be necessary.
Cheyenne/Southeastern Wyoming (307) 635-0555
Fort Collins/Larimer County area (970) 224-5200
Greeley/Weld County area (970) 454-1100
All other locations throughout
Wyoming and Northern Colorado (800) 442-2393
PLEASE INCLUDE YOUR TELEPHONE NUMBERS (WITH AREA CODES) HERE SO THAT WE MAY REACH YOU IF NECESSARY WITH REGARD TO YOUR WORKSHEETS.
NAME(S): ________________________________ _______________________________________
HOME PHONE: HUSBAND CELL PHONE: _______________ WIFE CELL PHONE: ____________
HUSBAND WORK: WIFE WORK: ______________________
MAY WE CALL YOU AND/OR LEAVE A DISCREET MESSAGE AT WORK? H: YES/ NO W: YES/ NO
DO YOU HAVE A FAX? YES/ NO THE NUMBER IS: ___________________________
MAY WE FAX YOU DOCUMENTS TO THIS NUMBER? YES/NO
LOKMPC REV 2012 E-MAIL: ________________________________
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CERTIFICATION OF ACCURACY. I have made my very best effort to completely, honestly, and thoroughly disclose my property, my obligations, and answer all questions on all pages that follow.
Done this day of , 20 .
___________________________________
Potential Client
I have read and agree with my spouse=s representation above.
___________________________________
Potential Client
CASH FLOW PLANNING
One of the principal reasons most households have financial problems is a failure to properly plan a budget. Most people budget money, but few realize that a commitment of future income that leaves less than sixty percent (60%) of expected income for contingencies is planning without emergency preparedness.
A good rule of thumb for family planning is to commit no more than forty percent (40%) of your disposable income to servicing debt. This rule may be the deciding factor in determining whether or not to file bankruptcy. It also is a standard by which the misuse of available credit is easily measured without guessing after bankruptcy.
To intelligently discuss the advisability of: (1) bankruptcy, (2) working out your debts without bankruptcy, and (3) to plan your future finances, you should fill out the following basic budget form meticulously.
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1. List your estimated average future monthly income for each spouse:
HUSBAND WIFE
Husband's monthly GROSS pay $ Wife's monthly GROSS pay $ ________
(there are 4.33 weeks per month)
Husband=s other monthly income $ Wife=s other monthly income $
(specify each)
TOTAL GROSS PAY $__________
PAYROLL DEDUCTIONS:
HUSBAND WIFE
Social Security/Medicare $ Social Security/Medicare $________
Federal Withholding $ Federal Withholding $________
State Withholding $ State Withholding $________
Insurance $ Insurance $________
Retirement $ Retirement $________
Other Deductions $ Other Deductions $________
(Please specify Aother@ deductions@
TOTAL DEDUCTIONS $____________
TOTAL NET PAY AFTER DEDUCTIONS $___________
2. List your best estimate of average future monthly expenses, consisting of:
a. Rent or Home Mortgage Payment $___________
(Include lot rental for trailer)
Does this payment include taxes and/or insurance? yes / no
b. Utilities: Electricity $ ,
Heat $ , Water $ ,
Telephone $ , Cable $ $___________
c. Home Maintenance (Repairs, Upkeep, etc.) $___________
d. Food ($ /wk x 4.33 wks/month) $___________
e. Clothing $___________
f. Laundry and Cleaning $___________
g. Medical, Dental and Drug Expenses $___________
h. Transportation (gas, oil, tires) $___________
i. Recreation, Entertainment, Newspapers $___________
j. Charitable Contributions $___________
k. Insurance (not deducted from wages)
Auto $ , Life $ , Health $ ,
Property $ Other $ (specify) $___________
l. Taxes (not deducted from wages, e.g. property, specify) $___________
m. Car Financing Payment $___________
n. Alimony, Maintenance or Support
Payments You Have To Pay $___________
o. Other Payments For Support Of
Dependents Not Living At Home $___________
p. Club/Union Dues (not deducted from wages) $___________
q. Day Care $___________
r. Other (specify) $___________
TOTAL COST OF YOUR NECESSITIES $___________
SUBTRACT THE COST OF YOUR NECESSITIES
FROM YOUR TOTAL NET PAY AFTER DEDUCTIONS
DISPOSABLE MONTHLY INCOME $___________
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These questions are designed to provide background information concerning financial affairs, and to point out possible problems if bankruptcy is an alternative in your planning. Answer them if you can or if they apply; if not, please indicate "no" or "not applicable." CAUTION: official bankruptcy forms will be prepared using the information contained in this questionnaire, and you will be required to sign the official bankruptcy forms under oath. The failure to provide complete and accurate information on the official bankruptcy forms can constitute a federal crime, and may result in your debts not being discharged in bankruptcy.
1. NAME AND RESIDENCE
a. What is your full name (including middle name) and social security number? (If Husband and Wife, give both names in full and both social security numbers). No middle initials, please. If you have no middle name or only an initial, please indicate.
NAME(s):
Husband: _______________________
Wife: _______________________
SSAN(s):
Husband: _______________________
Wife: _______________________
b. What is your current marital status? Please mark one of the following:
Single [ ] Married [ ] Divorced [ ] Widowed [ ]
c. Have you used, or been known by, any other names within the last 6 years? (If so, list all names used).
____________________________ ______________________________
d. Dependents of Debtor(s):
NAMES AGE RELATIONSHIP
___________________________ _____ ______________
___________________________ _____ ______________
e. Where do you now reside - give physical street address. Also give current mailing address if different than street address.
PHYSICAL ADDRESS: __________________________________
COUNTY: __________________________________
MAILING ADDRESS: __________________________________
f. Where else have you resided during the last 2 years? Give address, state, and dates of occupancy.
_______________________________ _________________________
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2. OCCUPATION AND INCOME
a. What is your occupation? (For Husband and Wife give both).
Husband - ______________________________
Wife - ______________________________
b. Where are you now employed? (IMPORTANT: Give the name and address of your employer(s), or the address at which you carry on your trade or profession, and the length of time you have been so employed or engaged. For Husband and Wife give both).
H - Employer: ________________________
Address: ________________________
________________________
Dates employed: ___________________
W - Employer: _________________________
Address: _________________________
_________________________
Dates employed: ____________________
c. Have you been in a partnership with anyone or engaged in any business during the last 6 years? (If so, give particulars, including names, dates and places).
_______________________________________________________________
d. What was your income for each of the previous two years according to your income tax return, or an approximation if you did not file a return? (For Husband and Wife, give both). Please bring copies of your tax returns to the initial consultation.
____________________ ____________________
e. What amount of income have you received from sources other than employment during each of these two years (for example, child support, gambling winnings, etc.)? (Give particulars including each source and the amount received therefrom).
_____________________________ _____________________
3. LOANS REPAID
a. List all payments on loans, installment purchases of goods or services, and other debts, aggregating more than $600.00 to any creditor within the last 90 days. Please include the name and address of the creditor, the dates of the payments, the amount paid and the amount still owed to that creditor.
____________________________________ __________________________
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b. List all payments of debts to relatives or business Ainsiders@ (partners, officers, etc.) made within the last year, regardless of the amount paid. Please include the name, address and relation of the person paid, the dates of the payments, the amount paid and the amount still owing.
__________________________________ ___________________________
4. SUITS, EXECUTIONS, GARNISHMENTS AND ATTACHMENTS
a. Are you a party to any suit pending at this time? If so, please provide a copy of the documents you have regarding the suit.
CASE NUMBER NATURE OF COURT AND STATUS OR
CAPTION OF SUIT PROCEEDING LOCATION DISPOSITION
_________________ _____________ _____________________ ______________
_________________ _____________ _____________________ ______________
b. Were you a party to any suit (including any divorces) terminated within the last year? If so, please provide a copy of the court papers regarding the suit or the divorce decree.
CASE NUMBER NATURE OF COURT AND STATUS OR
CAPTION OF SUIT PROCEEDING LOCATION DISPOSITION
_________________ _____________ _____________________ ______________
c. Has any of your property been attached, garnished, or seized under any legal or equitable process within the last year? (If so, describe the property seized or person garnished and at whose suit. Include copies of garnishment papers.
________________________________________________________________
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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 within one year immediately preceding the commencement of this case.
DATE OF REPOSSESSION, DESCRIPTION
NAME AND ADDRESS FORECLOSURE SALE, AND VALUE OF
OF CREDITOR OR SELLER TRANSFER OR RETURN PROPERTY
______________________ _________________________ _________________
6. RECEIVERSHIPS, GENERAL ASSIGNMENTS, AND OTHER MODES OF LIQUIDATION
a. Have you made any assignment of your property for the benefit of your creditors or any general settlement with your creditors within the preceding year? (If so, give dates, names and addresses of the assignee or settlement).
_______________________________________________________________
b. Is any of your property in the hands of a Receiver, Trustee, or Liquidating Agent? (If so, give a brief description of the property, the name and address of the Receiver, Trustee, or other Agent; and if the Agent was appointed in a Court proceeding, the name and location of the Court, the title and number of the case and the nature thereof).
_______________________________________________________________
7. GIFTS
Have you made any gifts other than ordinary and usual presents to family members and charitable donations during the last year? (If so, give names and addresses of donees and dates, description and value of gifts).
___________________________ _______________________________
___________________________ _______________________________
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8. LOSSES
a. Have you suffered any losses from fire, theft, or gambling during the last year? (If so, give details).
DESCRIPTION DESCRIPTION OF DATE OF
AND VALUE CIRCUMSTANCES LOSS
___________________ __________________________ _________________
___________________ __________________________ _______________
b. Was the loss covered in whole or in part by insurance? (If so, give the particulars).
____________________________________
9. PAYMENTS OR TRANSFERS TO ATTORNEYS
a. Have you consulted an attorney during the last year?
(Give dates, names, and addresses).
____________________________________________________________________
______________________________________________________________________
b. Have you during the last year paid any money or transferred any property to the attorney or to any other person on his behalf? (If so, give particulars including amount paid or value of property transferred and date of payment or transfer).
____________________________________________________________________
______________________________________________________________________
c. Have you during the last year agreed to pay any money or transfer any property to an Attorney At Law or to any other person on his behalf? (If so, give particulars, including amount and terms of obligation).
____________________________________________________________________
____________________________________________________________________
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10. TRANSFERS OF PROPERTY
Answer yes or no to the following. If you answer yes to any question, please provide details in the space provided below. Attach an additional sheet or use the back of this sheet if more space is necessary.
Y / N Have you sold, traded, or given away any vehicles, motorcycles, motor homes, or mobile homes in the past year?
Y / N Have you sold or given away any real property (real estate) in the past year?
Y / N Have you had a garage or yard sale in the past year?
Y / N Have you sold or given away any other personal property of any kind in the past year?
DATE SOLD: __________________________________________________
AMOUNT RECEIVED: ______________________ _____________________
SOLD TO WHOM? (NAME, ADDRESS, RELATIONSHIP TO YOU):
_______________________________________________________________
MONEY USED FOR?: _____________________ ______________________
DESCRIPTION OF PROPERTY AND VALUE: ____
11. BANK ACCOUNTS
What bank accounts have you maintained, alone or together with any other person, and in your own or any other name within the last two years? (Give the name and address of each bank, the account number, the name in which the deposit is maintained, and the name and address of every other person authorized to make withdrawals from such account. Include any accounts which have been closed in the last two years and their account numbers and the dates the accounts were closed).
BANK NAME NAMES ON CHECKING OR ACCOUNT OPEN OR
AND ADDRESS ACCOUNT SAVINGS? NUMBER CLOSED?
________________ ______________ ______________ __________ __________
________________ ______________ ______________ __________ __________
________________ ______________ ______________ __________ __________
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12. SAFE DEPOSIT BOXES
What safe deposit box (or boxes) or other depository (or depositories) have you kept or used for your securities, cash, or other valuables within the last two (2) years?
NAME AND ADDRESS NAMES AND ADDRESSES
OF BANK OR OTHER OF THOSE WITH ACCESS DESCRIPTION
DEPOSITORY TO BOX OR DEPOSITORY OF CONTENTS
________________________ ___________________________ _________________
13. SETOFFS (UNAUTHORIZED PAYMENTS)
List all setoffs (payments or withdrawals of your money by your creditors for the purposes for paying a debt, other than wages garnishments) made by any creditor, including a bank, against a debt or deposit of yours within the last 90 days.