Client Questionnaire

For Non-Business

Debtor

Basic Information How Did You Learn About Us? Filing Status: CHAPTER 7 CHAPTER Individual and unmarried Individual, married and living apart Individual, married and living together Joint and living together Joint and living apart Marital Status: Never married --- Divorced --- Widowed __ Married and living together __ Married and living apart Gender: Male Female Part A. NamE! and Address
Name: l.sst Telephone Number Home: Cellular: Have you used any other names in the past six years? 0 First _ _ No 0 Yes If yes, list other names: Date of Birth: _ Work: Middle _

13

Social Security Number: Driver's License No. Address: City: County: State: Zip:

Have you lived at this address for at least 180 days?

No

Yes

If you have a different mailing address, please list: Mailing Address: City: State: _ Zip:

Have you moved within last 2 years? If yes, state prior address and dated moved:

Yes

No _

Part B. Name and Address of Spouse

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

Name:----~L-a--s~t----------------------~F=lf-s~t----------------------~M~/~a~&~e--------------Telephone Number Home: Cellular: Has your spouse used any other names in the past six years? _ Work:

No

Yes

If yes, list other names:

Social Security Number: Driver's License No. Address: City: State: _ Zip:

Date of Birth:

County:

If your spouse has a different mailing address, please list: Mailing Address: City: State: _ Zip:

Have you moved within last 2 years? If yes, state prior address and dated moved:

Yes

No _

Prlor/Pendinq Bankruptcy Cases

Has a bankruptcy case been filed by you or against you in the last 8 years? If yes, in which district of which state was the case filed? Case Number: _________________ Date filed: 0 No 0 Yes

Are there currently any bankruptcy cases pending against you, your business, your spouse, or your spouse's business? 0 No 0 Yes If yes, name of debtor: Case Num ber: Date filed: Relationship Judge: to you: _ _

In which district of which state was the case filed?

---------------------------------

Exhibit "C" to tlhe 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? 0 No 0 Yes (If yes, please list and describe the property.)

Real Estate
List all real estate which you own or are a joint owner of, even if you still owe money on the property. PROPERTY A[IDRESS:

Purchase Date: Owners:

Purchase Price:

Current Value:

MORTGAGE

INFORMATION:

First Mortgage Name & Address:

If co-owners

or co-siqners on the note, please list name and address and relationship:

Account Number: Balance Due: Is Property in Foreclosure?

Interest Rate: Monthly Payment: Yes No

Payment Due Date: __ No. of months delinquent:

If yes, date of sale:

Name, address & phone number of attorney for mortgage company?

SECOND
2ND

MORTGAGE:

Mortgage Co Name & Address:

If co-owners

of Go-signers on the note, please list name and address and relationship:

Account Number: Balance Due: .

_________

Interest Rate: Monthly Payment: Yes No

_ _

Payment Due Date: No. of months delinquent: __ _

Is property in foreclosure?

If yes, date of sale:

Name, address & phone number of attorney for mortgage company?

IF YOU OWN ANY ADDITIONAL REAL PROPERTY (such as rental properties) LIST THEM ON ADDITIONAL PAPER OR ON THE REVERSE SIDE INCLUDING ALL OF THE ABOVE INFORMATION

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RENTERS

If you rent property, Landlord: Address:

such as an apartment

or house, please fill in all questions

listed below: _

-----------------------------------------------------------------------Month Iy Paym ent: _

How long is lease:

Personal Property
AUTOMOBILE Yea r: Mileage: Current Value: Date Purchased: Make: Years Financed: _ _ _ Loan Am ou nt: Model: P u rch a se Price: _ _ _

LENDER Lender's Lender's Name: Address:

Account Monthly

Number: Payment: No

Balance

of Loan:

No. of months Keep/Surrender

delinquent:

__

Due date every month: Yes

Car (Circle one) _

Any co-signers?

Co-s ig ne rs n a me, add ress and relation sh ip

2ND

AUTOMOBILE Yea r: Mileage: Current Value:

Date of Purchase: M a k e: _

----------------_ Model: _

Loa n Am

0 u nt:

_ _

Years Financed:

Pu rchas e Price:

LENDER Lender's Lender's Name: Address:

Account Monthly

Number: Payment: No

Balance

of Loan:

No- of months Keep/Surrender

delinquent:

__

Due date every month: Yes

Car (Circle one) _

Any co-signers?'

Co-s ig n e rs n a me, ad dress and re lation ship:

IF YOU OWN ANY ADDITIONAL AUTOMOBILES, ALL INFORMATION LISTED ABOVE

LIST THEM ON THE REVERSE

SIDE AND INCLUDE

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Personal Property

(continued)

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 market value as the yard sale value. 1. How much cash do you have on hand: --"$:...--

2. List checking and savings accounts, cert of deposits, credit unions, etc: Name of institution/location: Account No. Type of account _ Nam e of institution/location: Account No. Type of account (Use reverse side to list additional institutions)

_ Balance:
.::;..$ _

_ Balance:
"'-$ _

3. Do you have any security deposits with landlords, public utilities, telephone company, etc? State the name and address of the institute holding the deposit and the amount of the deposit being held: _

4. HOUSEHOLD GOODS AND FURNISHINGS: Please check off all household goods that you own. If you own more than one of these items, place a number on the right side of the item. List the yard sale value of each item listed. EXAMPLE: LIVING ROOM: Couch Chair Lamps Stereo

3 2

$ $ $

150.00 75.00 25.00

Love Seat Tables TV

$----$__ --"-50:::..: ..:::..00~ $ 1:...:.7..::.5.;..:.0,-",0_

$-----

LIVING ROOM: Couch Chair Lamps Stereo DINING ROOM: Table China Cabinet KITCHEN: Table Misc Cooking & Eating Utensils $----Chairs

$----$----$----$------

Love Seat Tables TV

$----$----$-----

$----$-----

Chairs Buffet

$----$-----

$-----

$-----

Misc

$-----

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DEN/FAMILY Couch Chair Lamps TV BEDROOMS: Beds ChlDwr Lamps TVs

R.OOM/BASEMENT:

$ $ $ $

Love Seat Tables Stereo

$ $ $

$
$

s
$

Dressers Tables Stereos

$
$ $

MiSe: Computers Fax Machine Bookshelves Art Objects

$ $ $ $

Printers Desk Pictures Antiques

$ $ $ $

ANY OTHER MISC ITEMS NOT LISTED ABOVE: 6. WEARING APPAREL:

7. Jewelry (list each item and value)

8. List all firearms, sport equipment and hobby equipment with yard sale value:

9. Do you have any life insurance policies: __ Yes No Term policy: _ Yes If yes, state with whom you have policy with, the type of policy, face and cash value of policy:

No

10. Do you have any interest in IRA, ERISA, Keogh or any other pension or profit sharing plans? If yes, list type and value of each:

11. Do you own any stock or interest in incorporated address, value and state your interest:

and unincorporated

business?

If yes, list nam e, _

12. Do you have any interests in partnerships

or joint ventures? If yes, Itemize and give value:

13. Do you own any government If yes, list them and give value:

and corporate bonds or other negotiable and nonnegotiable

instruments? _

14. Any accounts receivables?

If yes, list them and give the value:

15. Any alimony, maintenance, and give value: .

support or property settlements

to which you are entitled.

If yes, explain _

16. Any federal or state tax refunds due this year: If yes, item ize and give value:

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17. Do you own any patents, copyrights, or other intellectual property?

Give description and value:

18. Any licenses, franchises or other general intangibles?

Give description and value:

19. Do you own any boats, motors and/or accessories?

If yes list make, model, year and value:

20. Do you own any trailers, tractors or other vehicles and accessories other than those listed under "Automobiles", If so, please describe and list value:

21. Do you own any aircraft and accessories?

If yes, describe and give value:

22. Do you own any machinery, fixtures, equipment, and supplies used in your business? and give value:

If yes, describe

23. List all animals you own and the value of each animal:

24. Do you grow any crops?

Give description and value:

25. Do you own any farming equipment and implements?

If yes, describe and give value:

26. Do you own any farming supplies, chemicals and feed?

If yes, describe and give value:

27. Do you own any other personal property of any kind not already listed?

If yes, describe and give value:

28. Has anyone died from whom you are going to inherit?

If yes, describe cash, property and value: __

29. Do you own any time shares? Time Share Address:

If yes, please provide the following information:

Purchase Date: Owners: Mortgage Information: Mortgage Name & Address:

Purchase Price:

Current Value:

If co-owners or co-signers on the note, please list name and address and relationship:

Account Number: Interest Rate: Payment Due Date: __ Balance Due: Monthly Payment: No. of months delinquent: Is Property in Foreclosure? Yes No If yes, date of sale: Name, address & phone number of attorney for mortgage company?

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30. Do you have a Homeowners following information: Monthly Payment: Name & Address:

or Condominium

Association

monthly fee? If yes, please provide the

No. of months delinquent:

__

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STATEMENT OF FINANCIAL AFFAIRS

Income from employment or operation of business: State your gross income from employment or operation of a business. If you have not received any income from employment during the two years immediately preceding this calendar year, check this box:

NONE

2012You $ 2011You $ 2010You $ 201 2 Spouse$ 201 1 Spouse$ 201 0 Spouse$

Income other than from employment

Source Source Source Source Source Source

of of of of of of

income: income: income: income: income: income:

--------------------------------------------------------------------

_ _ _

or operation

of business:

(Social Security, Pension, Rental, etc)

State the amount of income received other than from employment or operation of business during the two years immediately preceding the commencement of this case.

201, 2011j;

4;

_
_

Source: Source:

Husband/Wife Husband/Wife

(circle one) (circle one) _

1. List each creditor who was paid more than $600.00 within the last 90 days:

2. List all property that has been repossessed by a creditor, sold at a foreclosure deed in lieu of foreclosure or returned to the seller, within the last year.

sale, transferred through a _

3. List the name of charity and date of all gifts or charitable contributions more than $200.00:

made within the last year worth _

4. List all losses from fire, theft or other casualty or gambling within the last year:

5. List all other property that you have transferred date of sale:

or sold within the last year, to whom it was sold and the

6.Have you closed or transferred any bank accounts within the last year? If so, list where they were closed or transferred from and where they were transferred to: _

7. List each safe deposit box or other box or depository in which you have or had securities, cash or other valuables within the last year: _

8. List all property owned by another person in your possession, including custodial accounts (for children)

9. List all business which you were involved with as an officer, director, or partner within the last two years:

10. List all bookkeepers

and accountants

and their addresses you have employed within the last six years:

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11. List all judgments

or lawsuits that have been filed by or against you.

Name of Plaintiff Case Number Name &. Address Of Court Plaintiff's Attorney Attorney Address

Date of Judgement Amount of Judgment Fill out the above information for each additional law suit.

12. Has the IRS or the State filed a tax lien against you? If the answer is yes, state the year(s) the lien(s) were filed, the amount of the lien and where the lien was recorded (court filed in).

13. List all Domestic Support Obligations

Recipients and their addresses

(Alimony and/or Child Support):

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Current Income
WE MUST HAVE THE LAST 6 MONTHS Marital Status: PAY STUBS OR PROOF OF INCOME

o Married o Single

List-all dependents of you and your spouse, their ages, and their relationshipto
--

you:

o Divorced
o Separated
o Widowed

Name

Age

Relationship

Debtor's Income
What is your occupation? Home long employed? Name and address of your employer: _

Joint Debtor's Income

What is your spouse's occupation? How long employed? Name and address of your spouse's employer: _

How often are you paid? _ _ Weekly, _

Monthly,

How often are you paid? _ _ Weekly, _

Monthly,

Every Two Weeks, Other

Every Two Weeks, Other

Twice a Month,

Twice a Month,

Do you or your spouse receive other income? (Retirement, social security, received, how often income is received and who receives the income:

part-time

job, etc) List from where, income _

Do you or your spouse

receive child support?

If so, state how much is received

per month and who receives

it: _

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Current Expenses
Do you and your spouse maintain separate households? and another for your spouse's. [J No [J Yes. If so, fill one page out for your household

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 am aunt. How many people in household included in your monthly expenses _

Indicate how much you pay for each item each month ...
your rent or your home mortgage Does that amount include real estate taxes? [J No Does it include property insurance? [J No electricity [J Yes [J Yes

$--------

and gas -"----$

water and sewage telephone service/long distance cell phones Do you have any other utility bills? If so, what, and how much per month?

$-------------$-------$------$ $-------------$-----_.

-------------home maintenance, food clothing laundry and dry cleaning medical and dental expenses transportation entertainment, (not including car payments) recreation, newspapers, magazines including repairs and general upkeep

$-----------$-------------$
$-----

$----$ $

charitable contributions insurance not deducted from paycheck homeowner's life insurance health insurance auto insurance other insurance _ or renter's insurance

$---------

$----------------

$----------------$-------$ $

taxes not deducted from paycheck (explain)

installment payments for car, furniture, etc. (Specify)

$ $------alimony, maintenance, support paid to others not living at home payments for support of dependents expenses from operation of business student loans child care pet care other expenses not listed above

$--------------$ $--------$---------$------$------$

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