Bankruptcy Information Form

Bankruptcy

AssessmentSurvey

(Please fill out COMPLETELY and in BLACK INKONLY)

Debtor’s Name: ______Date of Birth: ______

Address: ______

City, State, Zip: ______

Mailing Address (if different): ______

Other Names Used in the Last 6 Years: ______

Marital Status: Single Divorced Widowed Married

Home Phone: ______Work Phone: ______

Social Security # or Tax ID # (if more than one, state all): ______

County You Live In: ______

(If Filing a Joint Petition, Please Complete Spousal Information)

Spouse’s Name: ______Date of Birth: ______

Address: (if same leave blank): ______

City, State, Zip: ______

Other Names Used in the Last 6 Years:______

Home Phone: ______Work Phone: ______

Social Security # or Tax ID # (if more than one, state all): ______

TYPE OF BANKRUPTCY

Individual Joint Partnership Business (Publicly Held Yes No)

Other (Describe): ______

______

Chapter 7 Chapter 11 (Business Only) Chapter 13

Type and Nature of Business:

______

Have you filed for Bankruptcy within the last 6 years? Yes  No

If Yes, Where ______

Date Filed ______Case Number ______

Date of Discharge ______or Date of Dismissal ______

Real Estate(If multiple properties are involved please use additional paper and list all)

Location: ______

______

Nature of Property: (residential, rental, etc.) ______

Ownership: Husband Wife  Joint Co-owner

Current Market Value: ______ Keep Surrender

Mortgage Held By: (1st Mortgager)

Name: ______Phone: ______

Address: ______

City, State, Zip: ______

Loan Number: ______

Amount Owed: ______Monthly Payment: ______

Current in Payments: Yes No

If NO, how many months are you behind ______, Dollar amount behind ______

Is Property in Foreclosure: ______Yes ______No

If YES, please give attorney name and address representing the creditors.

Name: ______Phone: ______

Address: ______

City, State, Zip: ______

Case Number: ______

Mortgage Held By: (2nd Mortgager)

Name: ______Phone: ______

Address: ______

City, State, Zip: ______

Loan Number: ______

Amount Owed: ______Monthly Payment: ______

Current in Payments:  Yes No

If NO, how many months are you behind? ______Dollar amount behind $______

Secured Debts(Autos, Boats, Motor Homes, Furniture, etc.)

Account #:______

Creditor’s Name: ______Phone: ______

Mailing Address: ______

City, State, Zip: ______

Item Description: ______Current Market Value: ______

Amount Owed: ______Monthly Payment: ______

SecuredYes No If YES, Keep Surrender

Account #:______

Creditor’s Name: ______Phone: ______

Mailing Address: ______

City, State, Zip: ______

Item Description: ______Current Market Value: ______

Amount Owed: ______Monthly Payment: ______

SecuredYes No If YES, Keep Surrender

Account #:______

Creditor’s Name: ______Phone: ______

Mailing Address: ______

City, State, Zip: ______

Item Description: ______Current Market Value: ______

Amount Owed: ______Monthly Payment: ______

SecuredYes No If YES, Keep Surrender

Account #:______

Creditor’s Name: ______Phone: ______

Mailing Address: ______

City, State, Zip: ______

Item Description: ______Current Market Value: ______

Amount Owed: ______Monthly Payment: ______

SecuredYes No If YES, Keep Surrender

Account #:______

Creditor’s Name: ______Phone: ______

Mailing Address: ______

City, State, Zip: ______

Item Description: ______Current Market Value: ______

Amount Owed: ______Monthly Payment: ______

SecuredYes No If YES, Keep Surrender

Miscellaneous Taxes Owed

(Check appropriate category)

 Extensions of credit in an involuntary case.

Claims arising in the ordinary course of the debtors business or financial affairs after the commencement of the case but before the earlier of the appointment of a trustee or the order for relief.

 Wages, salaries and commissions.

Wages, salaries and commissions, including vacation, severance and sick leave pay owing to employees, up to a maximum of $2,000 per employee, earned within 90 days immediately preceding the filing of the original petition, or the cessation of business, whichever occurred first.

 Contributions to employee benefit plans.

Money owed to employee benefit plans for services rendered within 180 days immediately preceding the filing of the original petition, or the cessation of the cessation of business whichever occurred first.

 Certain farmers and fishermen.

Claims of certain farmers and fishermen, up to a maximum of $2,000 per farmer or fisherman against the debtor.

 Deposits by individuals.

Claims of individuals up to a maximum of $900 for deposits for the purchase, lease or rental of property or services for personal, family or household use, that were not delivered.

 Taxes and Certain Other Debts Owed to Governmental Units.

Taxes, customs duties and penalties owing to federal, state and local government units.

Account #: ______Amount Owed: ______

Creditor’s Name: ______Phone: ______

Mailing Address: ______

City, State, Zip: ______

Debt Type and Date Incurred: ______

Account #: ______Amount Owed: ______

Creditor’s Name: ______Phone: ______

Mailing Address: ______

City, State, Zip: ______

Debt Type and Date Incurred: ______

Account #: ______Amount Owed: ______

Creditor’s Name: ______Phone: ______

Mailing Address: ______

City, State, Zip: ______

Debt Type and Date Incurred: ______

Miscellaneous Unsecured Debts(Credit Cards, Medical, Utilities, Services, Subscriptions, etc.)

Account #:______

Creditor’s Name: ______Phone: ______

Mailing Address:______

City, State, Zip:______

Type of Credit:______Amount Owed: ______

Account #:______

Creditor’s Name: ______Phone: ______

Mailing Address:______

City, State, Zip:______

Type of Credit:______Amount Owed: ______

Account #:______

Creditor’s Name: ______Phone: ______

Mailing Address:______

City, State, Zip:______

Type of Credit:______Amount Owed: ______

Account #:______

Creditor’s Name: ______Phone: ______

Mailing Address:______

City, State, Zip:______

Type of Credit:______Amount Owed: ______

Monthly Income

Dependents of Debtor and Spouse

Names:______Age: ______Relationship: ______

______Age: ______Relationship: ______

Employment

Debtor:Occupation: ______

Name of Employer: ______

How Long Employed: ______

Address of Employer: ______

Spouse:Occupation: ______

Name of Employer: ______

How Long Employed: ______

Address of Employer: ______

Income:Debtor Spouse

Monthly Gross Wages, Salary and Commissions:$______$______

Estimated Monthly Overtime:$______$______

Payroll Taxes and Social Security:$______$______

Insurance:$______$______

Union Dues:$______$______

Other (Specify):$______$______

Net Monthly Income Take Home Pay:$______$______

Regular Income from Operation of Business:$______$______

Income from Real Estate Property:$______$______

Interest and Dividends:$______$______

Alimony, Maintenance or Support Payments:$______$______

Social Security or Government Assistance:$______$______

Specify: ______

Pension or Retirement Income: $______$______

Other Monthly Income:$______$______

Specify: ______

MONTHLY EXPENSES

(If a joint petition is filed and debtor’s spouse maintains a separate household,

complete a separate list of monthly expenses.)

Dollar AMT.

Rent or Home Mortgage

1st mortgage:$______

2nd mortgage:$______

Are real estate taxes included: Yes No

Is homeowners insurance included: YesNo

Utilities

Electricity:$______

Gas:$______

Water and Sewer:$______

Telephone:$______

Portable Phones:$______

Garbage Pickup:$______

Cable:$______

Other:$______

Home repairs and upkeep:$______

Food:$______

Clothing:$______

Laundry and dry cleaning:$______

Medical/dental:$______

Transportation/auto upkeep (not including car payments):$______

Recreation, clubs, newspapers, etc.$______

Charitable contributions:$______

Insurance (not deducted from wages or included in mortgage)

Homeowners or renters insurance:$______

Life insurance:$______

Health insurance:$______

Auto insurance:$______

Other:$______

Taxes (not deducted from wages or included in mortgage):$______

Describe: ______

Installment payments:

Auto:$______

Other:$______

Alimony, maintenance and support paid:$______

Payments for support of dependents not living at your home:$______

Regular expenses from operation of business:$______

Other:$______

Additional Required Information

Income from Employment or Operation of Business for Last 2 Years: (State Year and Amount)

Debtor: ______

Spouse: ______

Income other than from Employment or Business for Last 2 Years: (State Year and Amount)

Debtor: ______

Spouse:______

Your Bank Accounts

Checking Account: YesNo

If Yes, Where ______

Balance: ______

Savings Account:YesNo

If Yes, Where______

Balance:______

Security Deposits:YesNoIf YES,

Purpose:______

To Whom:______

Dollar Amount:______

Property You OwnVALUE

Boats, Motors and Accessories: (Describe)$______

______

Household Goods, Electronics, Computer, etc.:$______

Misc. Collectibles:$______

Wearing Apparel:$______

Furs and Jewelry:$______

Firearms, Sports/Hobby Equipment:$______

Autos, Trucks, Trailers and other Motor Vehicles: (Describe)$______

______

Aircraft and Accessories: (Describe)$______

______

Office Equipment, Supplies, Furnishings:$______

Tools of Trade:$______

Machinery/Equipment, etc. used in Business:$______

Inventory:$______

Animals:$______

Crops, Growing or Harvested:$______

Farming Equipment:$______

Farm Supplies, Chemicals and Feeds:$______

Other Personal Property not listed: (State Type and Current Value)$______

______

Retirement Accounts: (State Type, Current Value, Cash Borrowing Value)

______

Stocks, CD’s, Money Market Accounts: (State Type, Current Value, Cash Borrowing Value)

______

Government and Corporate Bonds: (State Type, Current Value, Cash Borrowing Value)

______

Life Insurance: (State Insurance Co., Present Value, Cash Borrowing Value)

______

Annuities: (Itemize, Name Each Issuer and State Value)

______

Alimony, maintenance, support or property settlements: (Describe and State Value)

______

Other liquidated debts including tax refunds: (Describe and State Value)

______

Interests in Partnerships, etc.: (Describe and State Value)

______

Interests in Estate of Descendents Death: (Describe and State Value)

______

Any and All Contingent and Unliquidated Claims: (Describe and State Value)

______

Patents and Copyrights: (Describe and State Value)

______

Licenses and Franchises: (Describe and State Value)

______

Accounts Receivable: (Value)

______

Any Unexpired Leases and or Executory Contracts: (Give Name, Address and Type)

______

Any Codebtors: (Give Name, Address for both Codebtor and Creditor:

______

Payments over $600 to Creditors within 90 days preceding this case: (Names and Amounts)

______

Lawsuits, Garnishments, etc.: (List Type, Creditor, Attorney’s Name/Address, Case Number, Amount)

______

Repossessions, Foreclosures and Returns within 1 year preceding this case: (Describe and State Amount)

______

Assignments and Receiverships within 120 days preceding this case: (Describe and State Amount)

______

Gifts or Charitable Contributions within 1 year preceding this case: (Name and Amount)

______

Losses, (fire, theft, gambling, etc.) within 1 year preceding this case: (State Type and Amount)

______

Payments Related to Debt Counseling or Bankruptcy within 1 year preceding this case: (Name and Amount)

______

Other property/financial transfers within 1 year preceding this case: (Describe and State Amount)

______

Closed, Sold or Transferred Financial Accounts within 1 year preceding this case: (Describe and State Amt)

______

Safe Deposit Boxes Holding Securities, Cash or Other Valuables: (Describe and State Amount)

______

Setoffs within 90 days preceding this case: (Describe and State Amount)

______

Property held for another person: (Name/Address of Owner, Property Location and Value)

______

Prior Address within 2 years preceding this case:

______

Bankruptcy Information

Bankruptcy law is a federal law. This sheet gives you some general information about what happens in a bankruptcy case. The information here is not complete. You may need legal advice.

When You File Bankruptcy:

You can choose the kind of bankruptcy that best meets your needs:

Chapter 7 – A trustee is appointed to take over your property. Any property of value will be sold or turned into money to pay your creditors. You may be able to keep some personal items and possibly real estate depending on the law of the state where you live.
Chapter 13 – You can usually keep your property, but you must earn wages or have some other source of regular income and you must agree to pay part of your income to your creditors. The Court must approve your repayment plan and your budget. A trustee is appointed and will collect the payments from you, pay your creditors, and make sure you live up to the terms of your repayment plan.
Chapter 12 – Like Chapter 13, but it is only for family farmers.
Chapter 11 – This is used mostly by businesses. In Chapter 11, you may continue to operate your business, but your creditors and the Court must approve a plan to repay your debts. There is no trustee unless the Judge decides that one is necessary; if a trustee is appointed, the trustee takes control of your business and property.

If you have already filed bankruptcy under Chapter 7, you may be able to change your case to another chapter.

Your bankruptcy may be reported on your credit record for as long as ten years. It can affect your ability to receive credit in the future.

What is a Bankruptcy Discharge and How Does It Operate?

One of the reasons people file bankruptcy is to get a “discharge”. A discharge is a Court Order, which states that you do not have to pay most of your debts. Some debts cannot be discharged. For example, you cannot discharge debts for:

Most taxes;
Child support;
Alimony;
Most student loans;
Court fines and criminal restitution; and
Personal injury caused by driving drunk or under the influence of drugs.

The discharge only applies to debts that arose before the date you filed.

Also, if the Judge finds that you received money or property by fraud, that debt may not be discharged.

It is important to list all your property and debts in your bankruptcy schedules. If you do not list a debt, for example, it is possible the debt will not be discharged.

The Judge can also deny your discharge if you do something dishonest in connection with your bankruptcy case, such as destroy or hide property, falsify records, or lie, or if you disobey a Court Order.

You can only receive a Chapter 7 discharge once every six years. No one can make you pay a debt that has been discharged, but you can voluntarily pay any debt you wish to pay. You do not have to sign a reaffirmation agreement or any other kind of document to do this.

Some creditors hold a secured claim (for example, the bank that holds the mortgage on your house or the loan company that has a lien on your car). You do not have to pay a secured claim if the debt is discharged, but the creditor can still take the property.

What is a Reaffirmation Agreement?

Even if a debt can be discharged, you may have special reasons why you want to promise to pay it. For example, you may want to work out a plan with the bank to keep your car. To promise to pay that debt, you must sign and file a reaffirmation agreement with the Court. Reaffirmation agreements are under special rules and are voluntary. They are not required by bankruptcy law or by any other law. Reaffirmation agreements:

Must be voluntary;
Must not place too heavy a burden on you or your family;
Must be in your best interest; and
Can be canceled anytime before the Court issues your discharge or within 60 days after the agreement is filed with the Court, whichever gives you the most time.

If you are an individual and you are not represented by an attorney, the Court must hold a hearing to decide whether to approve the reaffirmation agreement. The agreement will not be legally binding until the Court approves it.

If you reaffirm a debt and then fail to pay it, you owe the debt the same as though there was no bankruptcy. The debt will not be discharged and the creditor can take action to recover any property on which it has a lien or mortgage. The creditor can also take legal action to recover a judgment against you.

If you want more information or have questions about how the bankruptcy laws affect you, you may need legal advice. The trustee in your case is not responsible for giving you legal advice.