GLENN WARD CALSADA

LAW OFFICES OF GLENN WARD CALSADA

23283 Ventura Boulevard

Woodland Hills, CA 91364

PHONE NUMBER: (818) 477-0314

FAX NUMBER: (818) 473-4277

EMAIL:

Website:

BASIC INFORMATION

DEBTOR / JOINT DEBTOR
Name (first, middle, last) /or Company Name:
All Other Names/DBAs Used:
Social Security No/Tax ID #:
Street Address:
City, State, Zip Code:
County of Residence:
Marital Status:
Age/Company Start Date:
Home Phone:
Work Phone:
Cell Phone/Email:
Mailing Address (if diff):

DEPENDANTS LIVING WITH YOU

Name / Age / Relationship

PRIOR BANKRUPTCY CASES

List ALL prior bankruptcy cases you have filed in any jurisdiction.

Where Filed: / Date Filed:
Case Number: / Judge:

List all pending bankruptcy cases filed by any Spouse, Partner, or Affiliate.

Name of Debtor: / Relationship:
Where Filed: / Date Filed:
Case Number: / Judge:

______INITIAL HERE

CREDIT COUNSELING REQUIREMENTS

Within the 180 days before the filing of your bankruptcy case, you must receive a briefing from a credit counseling agency approved by the United States trustee or bankruptcy administrator that outlined the opportunities for available credit counseling and assisted you in performing a related budget analysis. You must have a copy of the certificate and a copy of any debt repayment plan developed through the agency before filing.

PERSONAL FINANCIAL MANAGEMENT COURSE

You are required to complete an instructional course in personal financial management by an approved personal financial management provider. Deadlines: In a chapter 7 case, file within 45 days of the first date set for the meeting of creditors. In a chapter 13 case, file no later than the last payment made by the debtor as required by the plan. If the certificate is not timely filed, the court will dismiss the case WITHOUT A DISCHARGE and you will have to pay a fee to reopen the case to get the discharge of your debts.

SCHEDULE A – REAL PROPERTY

Description and
Location / Owner / Nature of
Interest / Current Value / TOTAL
Amount Of
Liens

SCHEDULE B – PERSONAL PROPERTY

Type of Property / Description and
Location of Property / Owner / Current Value
(Garage Sale)
Cash on Hand
Bank Accounts
Security Deposits
Household Goods and Furnishings
Books, Pictures, and other Collectibles
Wearing apparel
Furs and Jewelry
Firearms, Sports, and other Equipment
Interest in Insurance Policies
Annuities
Interest in Education IRA; Pension or Profit Sharing Plans
Stock and Business Interest
Government orCorporate Bonds
Account Receivable
Alimony, Maintenance, Support, etc.
Other Liquidated Debts
Equitable or Future Interests
Interests in Estate of a Decedent
Patents, Copyrights, etc.
Customer Lists
Automobiles, Trailers, etc.
Boats, Motors, Aircraft, etc.
Office Equipment, Furnishings,Supplies
Business Machinery, Fixtures, etc.
Inventory
Animals and Crops,
Farming Equipment, Supplies, etc.
Other Personal Property Not Listed

SCHEDULE D ~ CREDITORS HOLDING SECURED CLAIMS

mortgages, auto loans, any bill secured with collateral, etc.

Creditor
Name and Address / Detailed
Description / Account
No. / Date
Incurred / Owner / Amount
Owed / Market
Value

SCHEDULES E & F ~ CREDITORS HOLDING UNSECURED CLAIMS

IRS, child support, credit cards, medical bills, lawsuits and any other bills without collateral

Creditor
Name and Address / Detailed
Description / Account
No. / Date
Incurred / Owner / Amount
Owed

SCHEDULE G – EXECUTORY CONTRACTS OR UNEXPIRED LEASES

Car leases, rentals and any other unfinished contracts or leases

Name and Address / Detailed Description / Amount of Money Owning

SCHEDULE H – CODEBTORS

Co-borrowers and guarantors and any joint debts with another

Name and Address of Codebtor / Name and Address of Creditor

SCHEDULE I – CURRENT MONTHLY INCOME

you must submit all pay stubs for the 6 months prior to filing

DEBTOR / JOINT DEBTOR
Occupation:
Length of employment
Employer’s Name:
Employer’s Address:
Employer’s City, State, Zip
How often paid:
DEBTOR / JOINT DEBTOR
Gross Wages, Salary, Commissions
Estimated Overtime
Regular Income From Business, Profession, Or Farm
Income From Real Property
Monthly Interest And Dividends
Monthly Alimony, Maintenance, Or Support Payments
Social Security Or Government Assistance
Pension Or Retirement
Other Monthly Income
Describe any increase or decrease of more than 10% in any previous category anticipated to occur in the year following filing.

SCHEDULE J – CURRENT EXPENDITURES

Estimate the average or projected monthly expenses of the debtor and the debtor’s family.

Rent Or Home Mortgage Payment / $
Property Taxes (if not included in mortgage payment) / $
Property Insurance (if not included in mortgage payment) / $
Electricity And Heating Fuel / $
Water And Sewer / $
Telephone / Cell Phone / $
Garbage / $
Cable / $
Other Utilities / $
Home Maintenance (Repairs And Upkeep) / $
Food / $
Clothing / $
Laundry And Dry Cleaning / $
Medical And Dental Expense (co-payments, prescriptions, etc.) / $
Transportation (not including car payments) / $
Recreation, Clubs And Entertainment, Newspapers, Magazines, etc. / $
Charitable Contributions / $
Homeowner’s Or Renter’s Insurance / $
Life Insurance / $
Health Insurance / $
Auto Insurance / $
Other Insurance – specify / $
Installment Payments: Auto, Other (details) / $
Alimony, Maintenance, And Support Paid To Others / $
Payments For Support Of Additional Dependents Not Living At Your Home / $
Regular Expenses From Operation Expenses Of Business, Profession, Or Farm / $
Other Expenses / $
Describe any increase or decrease in expenditures reasonably anticipate to occur within the year following the filing of this document / $

STATEMENT OF FINANCIAL AFFAIRS

1. Gross Income from employment or operation of business; enter each income source for the past two years.

Source
(name and address) / Amount / Fiscal Period

2. Gross Income other than from employment or operation of business; enter each income source for the past two years.

Source
(name and address) / Amount / Fiscal Period

3. List payments made to any creditor during the last 90 days.

Creditor
(name and address) / Dates of
payments / Amount paid / Amount
still owing

4a. List any all suits and administrative proceedings during the last year.

Caption of Suit
Case Number / Nature of
Proceeding / Court or Agency and Location / Status or
Disposition

4b. List any property garnished, attached or seized during the last year by a creditor.

Name and Address for
Whose Benefit Property was Seized / Date of
Seizure / Description and Value
of Property

5. List any repossessions, foreclosures, and voluntary returns during the last year.

Name and Address for
Whose Benefit Property was Seized / Date of
Seizure / Description and value
of Property

6a. Describe any assignment of property for the benefit of creditors made within the last 120 days.

Name and Address
of Assignee / Date of
Assignment / Terms of Assignment
or Settlement

6b. List all property which has been in the hands of a custodian, receiver, etc. during the past year.

Name and Address
Of Custodian / Court Case Title
and Case Number / Date of
Order / Description and Value of Property

7. List all gifts or charitable contributions made during the last year.

Recipient
(name and address) / Relationship (if any) / Date of
Gift / Description and value
of gift

8. List all losses from fire, theft, other casualty or gambling during the past year.

Description and
Value of Property / Description and Circumstances
Was Loss was Covered by Insurance / Date of
Loss

9. List all payments made or property transferred related to debt counseling or bankruptcy.

Name and Address
of Payee / Date of
Payment / Amount paid
or value of property transferred

10a. List all property, other than property transferred in the ordinary course of the business or financial affairs of the debtor, transferred either absolutely or as security during the past two years to creditor or family member

Name and Address of Transferee
and Relationship to Debtor / Date / Describe Property
Transferred / Value Received

10b. List all other property transferred by the debtor during the part ten years to a self settled trust or similar device of which the debtor is a beneficiary.

Name of Trust
or Other Device / Date / Describe Property
Transferred / Value

11. List all financial accounts and instruments which were closed, sold, or otherwise transferred in the past year.

Institution
Name and Address / Account Type
and Account Number / Amount of
Final Balance / Amount
Date of Sale

12. List each safe deposit or other box or depository in which you have had valuables within the past year.

Institution
(Name And Address) / Who Has Access?
(Name And Address) / Description
Of Contents / Date of Transfer or Surrender

13. List all setoffs (money taken from an account to repay a loan at the same bank as where your money has been deposited) made by any creditor, including a bank, against a debt of the debtor within the past 90 days.

Creditor
(Name And Address) / Date Of Setoff / Amount
Of Setoff

14. List all property owned by another person or entity that you and your spouse holds or controls.

Owner
(Name And Address) / Description And Value
Of Property / Location
Of Property

15. List all premises occupied and vacated during the past three years.

Address / Name Used / Dates Of Occupancy

16. Identify the name of spouse or former spouse who resided with you in a community property state (AK, AZ, CA, ID, LA, NV, NM, PR, TX, WA, or WI) in the eight years.

Name / Address

17a. List the name and address for which your corporation has received notice in writing by a governmental unit that the corporation may be liable or potentially liable under or in violation for an Environmental Law.

Site Name And Address / Name And Address Of Governmental Unit / Date
Of Notice / Environmental
Law

17b. List the name and address of every site for which you provided notice to a governmental unit of a release of Hazardous Material.

Site Name And Address / Name And Address Of Governmental Unit / Date
Of Notice / Environmental
Law

17c. List all judicial or administrative proceedings, including settlements or orders, under any Environmental Law with respect to which you are or were a party.

Name And Address
Of Governmental Unit / Docket Number / Status Or Disposition

18. List all businesses in which you were an officer, director, partner, or managing executive of a corporation, partnership, sole proprietorship, or were a self-employed professional within the last six years, or in which your owned 5 percent or more of the voting or equity securities within the last six years.

Name / Last four digits of Soc. Sec. No. / Completed EIN or other taxpayer I.D. No. / Address / Nature of business / Beginning and ending dates

19a. List all bookkeepers and accountants who within two years immediately preceding the filing of this bankruptcy case kept or supervised the keeping of books of account and records of the debtor.

Name and Address / Dates of Services Rendered

19b. List all firms or individuals who within two years immediately preceding the filing of this bankruptcy case have audited the books and records, or prepared a financial statement of the debtor.

Name and address / Dates of Services Rendered

19c. List all firms or individuals 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

Name and Address / Explain

19d. List all financial institutions creditors and other parties, including mercantile and trade agencies, to whom a financial statement was issued within the last two years immediately preceding the commencement of this case by debtor.

Name and Address / Date Issued

20a. 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.

Date of Inventory / Inventory Supervisor / Dollar Amount of Inventory
(Specify Cost, Market of Other basis)

20b. List the names and address of the person having possession of the records of each of the inventories reported in a., above.

Name and Address / Date Issued

21a. If the debtor is a partnership, list the nature and percentage of partnership interest of each member of the partnership

Name and Address / Nature of Interest / Percentage of Interest

21b. 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 percent or more of the voting or equity securities of the corporation.

Name and Address / Title / Name and Percentage of Stock Ownership

22a. If the debtor is a partnership, list each member who withdrew from the partnership within one year immediately preceding the commencement of this case.

Name and Address / Nature of Interest / Percentage of Interest

22b. 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.

Name and Address / Nature of Interest / Percentage of Interest

23. 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 prerequisite during one year immediately preceding the commencement of this case.

Name and Address / Nature of Interest / Percentage of Interest

24. 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 anytime within the six-year period immediately preceding the commencement of the case.

Name of Parent Corporation / Taxpayer Identification Number (EIN)

25. If the debtor 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 six years immediately preceding the commencement of the case.

Name of Parent Corporation / Taxpayer Identification Number (EIN)

EXHIBIT C

Identify and briefly describe all real or personal property owned or in possession that poses or is alleged to pose a threat of imminent and identifiable harm to the public health or safety.
With respect to each parcel of real property or item of personal property identified in question 1, describe the nature and location of the dangerous condition, whether environmental or otherwise, that poses or is alleged to pose a threat of imminent and identifiable harm to the public health or safety.

STATEMENT OF MILITARY SERVICE

Are you or your spouse a disabled veteran whose indebtedness occurred primarily during a period in which you were on active duty or while I was performing a homeland defense activity.
Yes: / No:
Identification of Service Member:
Type of Military Service:
Active Service Since:
Inductee – Order to Report On:
Retired / Discharged:
Service Member Deployed Overseas On:
Anticipated Completion of Overseas Tour-of-Duty:

BUSINESS INCOME AND MONTHLY EXPENSES

Gross Business Income for past 12 months: / $
Gross Average Monthly Income: / $
Net Employee Payroll: / $
Payroll Taxes: / $
Unemployment Taxes: / $
Worker’s Compensation: / $
Other Taxes: / $
Inventory Purchases: / $
Purchases of Feed/Fertilizer/Seed/Spray: / $
Rent: / $
Utilities: / $
Office Expenses and Supplies: / $
Repairs and Maintenance: / $
Vehicle Expenses: / $
Travel and Entertainment: / $
Equipment Rental and Leases: / $
Legal/Accounting/Other Professional Fees: / $
Insurance: / $
Employee Benefits (e.g. pension, medical, etc.): / $
Payments to Be Made Directly by Debtor to Secured Creditors / $
Specify:
Other: / $
Specify:

PLEASE SIGN BELOW AND RETURN BY FAX (818) 473-4277 OR EMAIL or in person.

All information provided in your bankruptcy filing is provided under oath and is subject to the laws of perjury. It is a crime to knowingly submit false information in conjunction with your bankruptcy filing. I/WE CERTIFY THAT THE ALL INFORMATION PROVIDED IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE.

______

DebtorSpouse

©2017 Bankruptcy Worksheets – Law Offices of Glenn Ward Calsada – Page 1