WilliamW.LawrenceChapter13BankruptcyTrusteeWesternDistrictofKentucky

310RepublicPlaza

200SouthSeventhStreet Louisville,KY40202 (502)581-9042

Dated:09/22/2011

CaseNo: 12-XXXX

Ima J Debtor

Self-EmploymentQuestionnaire

TheTrusteerequiresalldebtorswhoareself-employedtocompletethe followingquestions.Allquestionsshouldbe answered;butyoumaynot haveallofthedocumentsorinformationrequested.

1.Descriptionofbusiness:

a)Listcurrentnamesandallpastnamesusedbythebusiness.

b)Typeofbusinessthat youoperate. c)Mainproductand/orservice.

d)Isyourbusinessa:

[]SoleProprietorship[]Partnership[]Corporation

e)Nameofowners.

f)Whendidthecurrentbusinessstartoperating?

g)Locationwherebusinessisoperated.

h)Areyouleasingofficespace?Ifyes,listallleases,terms ofeachlease,andifyouwishtocontinueeachlease.

i)A.reyouleasinganybusinessequipment?Ifyes,listall leases,termsofeachlease,andifyouwishtocontinueeach lease.

j)Isyourbusinessseasonal?Ifyes,specifyyourgoodmonthsand poormonthsandreasonforfluctuation.

k)Doyouincuranytradecreditinordertoprocureincomefor yourbusiness?Ifso,statewhoextendstradecredittoyoufor yourbusiness.

1)Haveyoupledgedyourreceivables,rent,profits,orothercash ascollateralforanyloans?Ifyes,pleaseidentifyassetor revenuepledged.

2.Descriptionofassets:

a)Onaseperatepage,describeeachitemwithavalueover$500.00.

Alsoinclude1)Whatyouwouldselltheitemforinitspresent

conditionandassumingafairprice;2)Howmuchtheitemcost

youoriginally;3)Theageofeachitem.

b)Whatwouldyouestimatethemarketvalueofyourinventoryto be,ifany?

c)Whatwouldyouestimatethemarketvalueofyouraccounts receivabletobe,ifany?

d)Ifyouwereto buyyourbusinesstoday,howmuchwouldyoupay for yourbusiness?

3.Descriptionofallbankaccountstowhichyouhaveaccess:

a)Providecopies,notoriginals,ofbankstatementsforall

accountsforthreemonthspriortothetimeoffilingyour Chapter13case.(Note:TheTrusteemayrequestcopiesofone ormorecancelledchecksfromthistimeperiodinorderto clarifydatacontainedinthebankstatements.)

b)Areyoutheonlyauthorizedsignatory(ies)ontheaccounts?If no,specifyotherpersonsthatareauthorizedsigners.

BankName / AccountNumber / TypeofAccount / Purpose

4.Listallfullandpart-timeemployees:(otherthanthedebtor(s))

NameofEmployee / Position/Function / MonthlySalary / Part/FuJITime

5.Proofofpaymentofemployeewithholdingtaxes:

a)Ifyouhaveemployees,providecopiesofproofofpayment3

monthspriortothemonthyourcasewasfiled.

6.Proofofpaymentofsalestaxes:

a)Ifapplicable,providecopiesofproofofpaymentsfor3months

priortothemonthyourcasewasfiled.

7.FederalTaxReturns:

a)Provideacopyofyourmostrecentfederaltaxreturns.

8.Insurance:

a)InadditiontotheinsurancelistedintheAffadavitofChapter

13Debtors,providecopiesofthedeclarationpageofthepolicy orbinderforthefollowing:

*BusinessLiabilityInsurance

*Worker'sCompensationInsurance

*Allotherinsuranceforwhichpremiumsarecurrentlybeing

paid

I/Wedeclareund.erpenaltyofperjurythattheforgoingstatementof informationistrueandcorrecttothebestofmy/ourknowledge, informationandbelief.

Dated:

Debtor1Signature

Debtor2Signature