Client Questionnaire for Non-Business Debtor

Client Questionnaire For Non-Business Debtor

Section 1  Basic Information

Part A. Name and Address

Name:

LastFirstMiddle

Telephone Number Home:______Work:______

Have you used any other names in the past eight years?  No  Yes

If yes, list other names: ______

Social Security Number: ______- ______- ______

Driver' License No.:______Expiration Date: ______Date of Birth: ______

Address:______

City:______State:______Zip: ______

County:______

Have you lived at this address for at least 180 days?  No  Yes

Have you lived at this address for at least 730 days (2 years)?  No  Yes

If you answered no to either of the questions above, please list your previous address:

Address:______

City:______State:______Zip:

County:______

If you have a different mailing address, please list:

Mailing Address:______

City:______State:______Zip: ______

Part B. Name and Address of Spouse

If you are filing jointly with your spouse, fill in the following information about your spouse:

Name:

LastFirstMiddle

Has your spouse used any other names in the past eight years?  No  Yes If yes, list other names: ______

Social Security Number: ______- ______- ______

Driver' License No.:______Expiration Date: ______Date of Birth: ______

Address:(if different from your address): ______

City:______State:______Zip:______County:______

If your spouse has a different mailing address, please list:

Mailing Address:______

City:______State:______Zip: ______

Part C. Prior/Pending Bankruptcy Cases

Has a bankruptcy case been filed by you or against you in the last 8 years?  No  Yes

If yes, in which district of which state was the case filed? ______

Case Number: ______Date filed: ______

Are there currently any bankruptcy cases pending against you, your business, your spouse, or your spouse’s business?  No  Yes

If yes, name of debtor: ______Relationship to you: ______

Case Number: ______Date filed: ______Judge: ______

In which district of which state was the case filed?

Exhibit "C" to the Voluntary Petition

Do you own or have possession of any property that poses or is alleged to pose a threat of imminent and identifiable harm to public health or safety?  No  Yes (If yes, please attach a list and description of the property.)

Debtors Who Reside as Tenants of Residential Property

If you rent your home, does a landlord hold a judgment against you?  No  Yes

If yes, please provide the name and address of the landlord:

Name:______

Address:______

City:______State:______Zip:

How did you select our Firm?

Referred by ______

YP

Prattville Progress

Wetumpka Progress

Millbrook Progress

Online ad

Knew someone in the firm

Facebook

Other______

Are you behind on house payments? No Yes Amount Behind $______
Are you behind on car payments? No Yes Amount Behind $______
Do you have a job or other regular income? No Yes
Are you co-signed on debts with anyone other than your spouse? No Yes Who? ______
Have you been an owner, part-owner or officer of a business in the last 6 years? No Yes
Do you own or rent your home? Own/Buying Rent Neither Lease-Purchase Contract
Have you bought or sold any real estate in the last 4 years? No Yes (If yes, when ______. What was the purchase or sale price______)
Do you owe taxes to the Federal Internal Revenue Service? No Yes How Much $______
Do you owe taxes to the State Internal Revenue Service? No Yes How Much $______
Have you filed your income tax returns for: (check all that apply) 2013 2014 2015
Do you have copies of the most recent 2 years’ tax returns? No Yes (NOTE: you are required to provide the most recent returns to the trustee, so you will need to obtain these if you do not have them)
Do you have any outstanding bad checks (other than to payday lenders)? No Yes
Do you have more than $750 in cash advances from a credit card or an open-ended credit plan in the last 70 days? No Yes
Have you spent more than $500 on what some might call a luxury in the past 90 days? No Yes
Do you have copies of your paystubs for the last 6 months? No Yes (we must have these to file your case)
Do you anticipate an increase or decrease of more than 10% of your total household income in the next year? No Yes
Have you sold or given away property to family members or friends in the last year? No Yes
Do you have a reason to sue anyone? No Yes (If you say ‘no’ and later file a suit, your suit could be dismissed. If you say ‘yes’ your attorney may need to be approved by the Trustee and the proceeds would first go toward paying your debts in the bankruptcy.)
Are you presently involved in a lawsuit? No Yes
Are you behind on paying child support or alimony? No Yes How Much? ______
Does anybody owe you money? No Yes
Do you have money in an IRA, 401(k), or other retirement pay? No Yes
Are you expecting an inheritance within the next 6 months? No Yes
Are you expecting a tax refund within the next 4 months? No Yes
How much do you normally get back in tax refunds each year? ______
What is your total income for 2014______, 2015______and year to date for 2016______?
If you are married, what was your spouse’s total income for 2014______, 2015______and year to date for 2016______?
What creditors may have liens against your property? ______
Do you receive any government assistance? What is the monthly amount? (Food Stamps, WIC, TANF, etc.)

Type: ______Amount: ______

Section 2  Property

Part A. Real Estate (Schedule A)

List all real estate which you own or are a joint owner of, even if you still owe money on the property. This could include your primary residence (house, condo or apartment (if owned)), additional residence(s), rental property, burial plot, undeveloped land and farm land:

Address and description of property / Owned by Husband, Wife, Joint or Community / Tax Value or Appraised Value within the last year / Your % ownership, or $ amount, if you and spouse are not sole owners / List all mortgages, home equity loans, and liens: / Office Use Only
Exemptions?
Address:
______
______
_____Bedrooms _____Baths
______Square Feet (if known)
______Acres (if known)
Circle one:
Reaffirm OR Surrender / Name(s) on deed/ mortgage
______
______
______
______/ $______/ ______% / 1stMortgage Company:______
Payoff Amount: ______Interest rate:_____%
Monthly Payment: $______Payments left_____
Amount Behind: $______
2nd Mortgage Company:______
Payoff Amount: ______Interest rate:_____%
Monthly Payment: $______Payments left_____
Amount Behind: $______
Address:
______
______
_____Bedrooms _____Baths
______Square Feet (if known)
______Acres (if known)
Circle one:
Reaffirm OR Surrender / Name(s) on deed/ mortgage
______
______
______
______/ $______/ ______% / 1st Mortgage Company:______
Payoff Amount: ______Interest rate:_____%
Monthly Payment: $______Payments left_____
Amount Behind: $______
2nd Mortgage Company:______
Payoff Amount: ______Interest rate:_____%
Monthly Payment: $______Payments left_____
Amount Behind: $______

**If you have additional properties to disclose, please use a separate sheet of paper, and list all information requested.

Part B. Personal Property (Schedule B)

For each type of property listed below, indicate whether you own any property of that category, and, if you do, fill in the remaining information. You can think of the value as the replacement value. For property acquired for personal or family use, replacement value is the price a retail merchant would charge for a property of that kind, considering the age and condition of that property.

Type of Property / Yes/ No / Description & Location / Husband, Wife, Joint, Community / Value / Office Use Only
Exemptions?
1. Cash on hand / $______
2. Checking/Savings Account, Certificates of deposit, other bank accounts / Checking: Bank:______
Bank:______
Savings: Bank:______
Bank:______/ ______
______
______
______/ $______
$______
$______
$______
3. Security deposits held by utility companies, landlord
4. Household goods and furnishings: / Beds and Bedding
Table and Chairs
Stove (if not part of the house)
Tableware
Cooking utensils
Refrigerator
Washer and Dryer
Entertainment Center
Coffee Tables & End Tables
Sofas & Loveseats
Chairs
Dressers & Chests-of-Drawers
Computer Desks
Other Furniture
Vacuum cleaner
______
TVs
VCR/DVD players
Stereo
Video Game System/Games
Computers/Printers
CDs/DVDs/Records/Videos
Cameras and video cameras
______/ ______
______
______
______
______
______
______
______
______
______
______
______
______
______
______
______
______
______
______
______
______
______
______
______/ $______
$______
$______
$______
$______
$______
$______
$______
$______
$______
$______
$______
$______
$______
$______
$______
$______
$______
$______
$______
$______
$______
$______
$______
5. Books, pictures, art objects, collectibles / $______
6. Clothing / $______
7. Furs and jewelry / Jewelry worn daily
Jewelry not worn daily
Furs / ______
______
______/ $______
$______
$______
8. Sports, photographic, hobby equipment, firearms / Cameras and video cameras
Athletic equipment
Firearms
______/ ______
______
______
______/ $______
$______
$______
$______
9. Interest in insurance policies-specify refund or cancellation value / $______
10. Annuities / $______
11. Interests in an education IRA, as defined in 26 USC § 530(b)(1) / $______
12. Interests in pension or profit sharing plans / $______
13. Stock and interests in incorporated/ unincorporated business / $______
14. Interests in partnerships/joint ventures / $______
15. Bonds / $______
16. Accounts receivable / $______
17. Alimony/family support to which you are entitled / Child Support
Alimony
Other______/ ______
______
______/ $______
$______
$______
18. Other liquidated debts owed to you, including tax refunds / $______
19. Equitable or future interests or life estates / $______
20. Interests in estate of decedent or life insurance plan or trust / $______
21. Other contingent/ unliquidated claims, including tax refunds, counterclaims / $______
22. Patents, copyrights, other intellectual property / $______
23. Licenses, franchises / $______
24. Customer List or other compilation / $______
25a. Automobiles, trucks, trailers, and accessories.
First Vehicle
Circle one:
Reaffirm OR Surrender / Year_____ Make______Model______
Trim (lx, ex, xlt, etc.)_____ Mileage ______
Interest Rate ____% Balance Owed $______
Monthly Payment $_____Months left on loan____
Amount behind on loan $______
Who drives this vehicle? ______
Check appropriate boxes: Manual Trans 4x4 Leather SeatsSunroof Damaged Not Running / Name(s) on Loan/Title
______
______
______
______
25b. Automobiles, trucks, trailers, and accessories.
Second Vehicle
Circle one:
Reaffirm OR Surrender / Year_____ Make______Model______
Trim (lx, ex, xlt, etc.)_____ Mileage ______
Interest Rate ____% Balance Owed $______
Monthly Payment $_____Months left on loan____
Amount behind on loan $______
Who drives this vehicle? ______
Check appropriate boxes: Manual Trans 4x4 Leather Seats Sunroof Damaged Not Running / Name(s) on Loan/Title
______
______
______
______
25c. Automobiles, trucks, trailers, and accessories.
Third Vehicle
Circle one:
Reaffirm OR Surrender / Year_____ Make______Model______
Trim (lx, ex, xlt, etc.)_____ Mileage ______
Interest Rate ____% Balance Owed $______
Monthly Payment $_____Months left on loan____
Amount behind on loan $______
Who drives this vehicle? ______
Check appropriate boxes: Manual Trans 4x4 Leather Seats Sunroof Damaged Not Running / Name(s) on Loan/Title
______
______
______
______
25d. Automobiles, trucks, trailers, and accessories / Such as: Utility Trailers
Other Trailers
Lawn Mowers
______/ ______
______
______
______/ $______
$______
$______
$______
26. Boats, motors, and accessories / $______
27. Aircraft and accessories / $______
28. Office equipment, supplies for business use / $______
29. Machinery, fixtures etc. for business use / $______
30. Inventory / $______
31. Animals / $______
32. Crops-growing or harvested / $______
33. Farming equipment and implements / $______
34. Farm supplies, chemicals, feed / $______
35. Other personal property of any kind not listed. / ______
______
______
______
______
______
______/ ______
______
______
______
______
______
______/ $______
$______
$______
$______
$______
$______
$______

Section 3  Debts

List below all debts that you owe, or that creditors claim that you owe.

Type of Debt / 1. Creditor Name and Address
2. Account Number, if any
3. Date/range of dates when debt was incurred
4. Contact person's name and address, if different / Amount owed / Name and address of codebtor, if any
What is debt for?
Is debt secured by any property? (If so, please list monthly payment and number of months left.) / Do you dispute the debt? / Office Use Only
Sched D, E or F? / Lawsuit pending? Collection agency assigned? Counsel for creditor?
Home loans/ mortgages (not listed in section 2)
Car loans (not listed in section 2)
Other bank loans
Personal loans
Student loans
Type of Debt / 1. Creditor Name and Address
2. Account Number, if any
3. Date/range of dates when debt was incurred
4. Contact person's name and address, if different / Amount owed / Name and address of codebtor, if any
What is debt for?
Is debt secured by any property? (If so, please list monthly payment and number of months left.) / Do you dispute the debt? / Office Use Only
Sched D, E or F? / Lawsuit pending? Collection agency assigned? Counsel for creditor?
Unpaid credit
cards, (Visa, Am Ex, MasterCard, Discover)
Department store credit card debts
Other credit card debts (Gas cards, phone cards, etc.)
Cash Advances (from credit cards)
Type of Debt / 1. Creditor Name and Address
2. Account Number, if any
3. Date/range of dates when debt was incurred
4. Contact person's name and address, if different / Amount owed / Name and address of codebtor, if any
What is debt for?
Is debt secured by any property? (If so, please list monthly payment and number of months left.) / Do you dispute the debt? / Office Use Only
Sched D, E or F? / Lawsuit pending? Collection agency assigned? Counsel for creditor?
Unpaid medical bills
Unpaid rent
Unpaid taxes
Unpaid alimony or child support
Unpaid service fees
All other unpaid debts/bills

Section 4  Unexpired Leases and Contracts (Schedule G)

List below any leases or contracts that are still current that you are a party to. Include residential, car and business leases, and service or business contracts.

Nature and Description of Contract / Name and Address of Other Party or Parties / Date that Contract Expires

Section 5  Current Income

Marital Status:
 Married
 Single
 Divorced
 Separated
 Widowed / List all dependents of you and your spouse, their ages, and their relationship to you:
Name
______
______
______/ Age
______
______
______/ Relationship
______
______
______
Part A. Debtor’s Income / Part B. Joint Debtor’s Income
1. What is your occupation? ______
2. Name and address of your employer:
______
______
______
3. How long have you been employed there? _____
4. What is the gross amount of your paycheck, before taxes/other deductions are taken out? $______
5. How often do you get paid?  once a week  every two weeks  twice a month  once a month  other______
Complete the below questions with your estimate of monthly averages.
6. Do you receive overtime pay outside of your salary? If so, how much per month? $______
7. How much is taken out of each paycheck for taxes and social security? $______
8. How much is taken out for insurance? $______
9. How much for union dues? $______
10. Are there other deductions? If so, what are they and how much? ______
Do you receive
a) income from business operations outside of your regular paycheck listed above? If so, what is the business and how much do you receive per month?
b) income from real estate property? If so, how much per month? No Yes $______
c) interest or dividends? If so, how much per month? No Yes $______
d) alimony or family support payments for your use or for the care of your dependents? If so, how much per month? No Yes $______
e) social security or other forms of monetary government assistance? No Yes $______
f) retirement or pension money? No Yes$____
Do you have any other sources of income not listed? / 1. What is your spouse’s occupation? ______
2. Name and address of your spouse’s employer:
______
______
______
3. How long employed there? ______
4. What is the gross amount of your spouse’s paycheck, before taxes/other deductions? $_____
5. How often does your spouse get paid?  once a week  every two weeks  twice a month  once a month  other______
Complete the below questions with your estimate of monthly averages.
6. Does your spouse receive overtime pay outside of his/her salary? How much per month? $______
7. How much is taken out of each paycheck for taxes and social security? $______
8. How much is taken out for insurance? $______
9. How much for union dues? $______
10. Are there other deductions? If so, what are they and how much? ______
Does your spouse receive
a) income from business operations outside of the regular paycheck listed above? If so, what is the business and how much does your spouse receive per month?
b) income from real estate property? If so, how much per month? No Yes $______
c) interest or dividends? If so, how much per month? No Yes $______
d) alimony or family support payments for spouse’s use or for care of dependents? If so, how much per month? No Yes $______
e) social security or other forms of monetary government assistance? No Yes $______
f) retirement or pension money? No Yes$____
Does your spouse have any other income not listed?
Are you or your spouse expecting any increase or decrease in salary next year?No Yes If so, explain.

Section 5A  Current Monthly Income

Fill in your monthly income for the categories below in the column labeled "Month 1." If your income for one of the below categories varies from month to month, complete the below chart by entering in your income for all six months.

Month 1
(last month)
___/___ / Month 2
(2 months ago)
___/___ / Month 3
___/___ / Month 4
___/___ / Month 5
___/___ / Month 6
___/___ / Office Use Only
Gross wages, salary, tips, bonuses, overtime, commissions.
Income from operation of business:
a. Gross Income
- b. Expenses
= c. Net Income.
Rent and other real property income:
a. Gross Income
- b. Expenses
= c. Net Income.
Interest, dividends, and royalties.
Pension and retirement income (NOT Social Security).
Regular contributions from others to the household expenses, including child support.
Unemployment Compensation.
Social Security income
Other sources not already mentioned. Specify:

Section 6  Current Expenses

Do you and your spouse maintain separate households?  No  Yes. If so, fill one page out for your household and another for your spouse’s.

The following questions ask for your expenses each month. If you are unsure of the amount you pay each month, but know the amount for a different period (per week, per day, every 2 months, etc.,), write in the amount and the frequency that you pay the amount.

Indicate how much you pay for each item each month…

1. your rent or your home mortgage$______

Does that amount include real estate taxes?  No  Yes

Does it include property insurance?  No  Yes

2. electricity and heating$______

3. water and sewage$______

4. telephone service/long distance$______

5. Do you have any other utility bills? If so, what, and how much per month?

______$______

6. home maintenance, including repairs and general upkeep$______

7. food $______

8. clothing$______

9. laundry and dry cleaning$______

10. medical and dental expenses$______

11. transportation (not including car payments) $______

12. entertainment, recreation, newspapers, magazines $______

13. charitable contributions$______

14. insurance not deducted from paycheck

a) homeowner’s or renter’s insurance$______

b) life insurance$______

c) health insurance$______