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BANKRUPTCY QUESTIONNAIRE (Please set your page set up at landscape orientation before printing)
THESE QUESTIONS ARE TO BE ANSWERED COMPLETELY, SPECIFICALLY AND LEGIBLY
Once the questionnaire is returned to our office with the $209.00 Filing Fee, we will begin preparing your petition. **If you are married, your questions apply to both you and your spouse. Always start with the man’s name. The woman is the spouse. If you are not filing jointly; ignore the questions about your spouse
1. State your full name: (no initials) ______________________________________ Your spouse’s name (no initials) _______________________________________ 2. Have you been known by any other name(s) in the past 6 years (include married, maiden and trade name) _________________________________________________________________ Your Spouse _______________________________________________________ 3. What is your social security number? ___________________________________ Your Spouse’s _____________________________________________________ 4. What is your street address? __________________________________________ _________________________________________________________________ Mailing address if different from street address? __________________________ _________________________________________________________________ Phone number (including area code) ____________________________________
Have you lived in New Jersey for at least 6 months prior to completing this Questionnaire? Yes ____ No ____ 4a. Do you rent an apartment? Yes ____ No____ 4b. Have you ever claimed bankruptcy before? If so when and where? _____________________________________________________________ SCHEDULE A: REAL PROPERTY 5. Do you own any property? Yes____ No____ 6. If so, please describe the property and location (this would also include a burial plot) __________________________________________________________ _______________________________________________________________ _______________________________________________________________ 7. What is your interest in the property?_________________________________ 8. What is the current market value of your interest in the property without deducting what you still may owe? _________________________________________ 9. How much do you still owe on the property?____________________________ 10. Do you have any cash on hand? Yes____ No ____. How much __________ 11. Do you have a checking account? Yes____ No ____, If so Name of Bank ____________________________________________________ Complete address _________________________________________________ Account Numbers _________________________________________________ In What name(s) __________________________________________________ Balance _________________________________________________________ Do you have more than one checking account? Yes ____ No ____ If so, please supply the same information on the back of this page. 12. Do you have a savings account? Yes ____ No ____, If so: Name of Bank ____________________________________________________ Complete address _________________________________________________ Account No. _____________________________________________________ Balance _________________________________ Do you have more than one savings account? Yes ____ No ____ If so, please supply the same information on the back of this page. 13. Do you have any security deposits with a public utility, telephone company, landlord, etc? Yes ____ No. ____. If so: Name of Person/ Company ___________________________________________ Complete address ___________________________________________________ Amount being held ___________________. Why?_______________________ 14. Do you have any household goods and furnishings, including audio, video and computer equipment? If so, please list: ITEM CURRENT VALUE (If sold at yard sale) __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________
15. Do you own any books, pictures and other art objects, antiques, stamps, coin record, tape, compact disc, and other collectibles or collections? Yes ____ No ____. If so, please describe below in detail. Also provide the market Value. _________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ 16. Do you own any wearing apparel of value (leather, etc) ? Yes ____ No ____. Please describe: __________________________________________ 17. Do you own any furs or jewelry? Yes ____ No ____. If so, please describe __________________________________ Value _________________________ 18. Do you own any firearms and sports, photographic and other hobby equipment? Yes ____ No ____. If so, please desribe: ______________________________________________Value ______________ 19. Do you have any insurance policies? Yes ____ No ____. If so, please provide the following: Name of Insurance Company __________________________________________ Complete Address __________________________________________________ Account number ____________________________________________________ Surrender value ____________________________________________________ 20. Do you have any annuities? Yes ____ No ____. If so, please itemize and name each issuer. __________________________________________________________________ 21. Do you have any interests in IRS, ERISA, Keogh, or other pension or profit sharing plans. Yes ____ No ____. If so, please itemize below and list the value __________________________________________________________________ __________________________________________________________________ 22. Do you have any stock and interests in incorporated and unincorporated businesses? If so, please itemize and list their value. _______________________ __________________________________________________________________ 23. Do you have interest in partnership or joint ventures? If so, please explain and list the amount _____________________________________________________ __________________________________________________________________ 24. Do you have any government and corporate bonds and other negotiable and non-negotiable instruments? Yes ____ No ____. If so please list below along with their value.____________________________________________________ _________________________________________________________________ 25. Are you entitled to alimony, maintenance, support and property settlements to which you may be entitled? Yes ____ No ____ If so, please explain and list the amount(s). _____________________________________________________ _________________________________________________________________ 26. Do you have any equitable or future interests, life estates, and rights or powers exercisable for the benefit of the debtor other than those listed in the Schedule of Real Property? Yes ____ No ____. If so please list along with the value: _________________________________________________________________ _________________________________________________________________ 27. Do you have any contingent and noncontingent interests in estate of a decedent, death benefit plan, life insurance policy or trust? Yes ____ No ____. If so please explain ____________________________________________________ 28. Do you have any other contingent or unliquidated claims of any nature, counterclaims and rights to set off claims? Yes ____ No ____. If so explain __________________________________________________________ 28a. How much do you expect to receive from your _______ Federal Income Tax? _____________ How much from the State? _________________ 29. Do you have any patents, copyrights and other intellectual property? Yes ____ No ____. If so, give particulars: _____________________________________ ________________________________________________________________ 30. Do you have any licenses, franchises and other general intangibles? Yes____ No ____. If so, explain: ____________________________________________ _________________________________________________________________ 31. Do you own or have an automobile in your name? Yes ____ No ____ VIN (Vehicle identification number) ____________________________________ PLEASE COMPLETE EVERY APPLICABLE BOX. Year _________ Make ________________ Model _____________ Sedan ____ Coupe ____ Pickup ____ Series ________ Hatchback ____ Station Wagon ____ 2 dr ____ 4 dr. ____ convertible ____ 4 cyl. ____ 6 cyl. ____ 8 cyl.. ____ diesel ____ turbo ____ Le ____ Se ____ Gl ____ Dl ____ Dx ____ other ____ power steering ____ tape player ____ cruise control ____ alloy wheels ____ leather interior ____ automatic trans. ____ manual trans.____ power door locks ____ power windows ____ power seats ____ anti lock brakes ____ Mileage ___________________. 32. Do you own a boat, motor or any accessories? Yes ____ No ____. If so please list item and value __________________________________________________ _________________________________________________________________ 33. Do you own aircraft or any accessories? Yes ____ No ____. 34. Do you own any office equipment, furnishings or supplies? Yes ____ No ____. If so please list the item and value ______________________________________ __________________________________________________________________ 35. Do you own any machinery, fixtures, equipment or supplies used in a business? Yes ____ No ____. If so list item and value: _____________________________ __________________________________________________________________ 36. Do you have any inventory? Yes ____ No ____. If so, please list items and value _____________________________________________________________ 37. Do you own any animals of value? Yes ____ No ____. If so, please list the type of animal and its value ________________________________________ 38. Do you own any crops – growing or harvested? Yes ____ No ____ 39. Do you own any farming equipment, farm supplies, chemicals or feed? Yes ____ No ____. If so, itemize and value ______________________________________ __________________________________________________________________ 40. Do you have any other personal property not listed? Yes ____ No ____. If so, please detail and give value: __________________________________________ _________________________________________________________________ EXEMPTIONS
41. Check the following items that you possess (which you would have previously described in the questionnaire). Household Goods ________________________ Automobile ________________________ Cash ________________________ Checking Account ________________________ Savings Account ________________________ Other Account ________________________ Life Insurance ________________________ Real Estate ________________________ Jewelry ________________________ Burial Plot ________________________ Collectibles ________________________
SCHEDULE D – CREDITORS HOLDING SECURITY A secured creditor is someone to whom you owe money, BUT they are secured because in the event you cannot pay them back, they are entitled to take something away from you. You would know if a creditor is secured by looking at the contract you signed. If you are not sure, please enclose a copy of the contract for the attorney check. An example of a secured creditor is a mortgage company or a company that gave you a car loan. The mortgage company could take your house and the company that gave you the car loan could repossess your car. 42. Do any creditors hold any secured title, lien, right or judgment against you? Yes ____ No ____. If so, please list the following: Name of Creditor ___________________________________________________ Complete Address __________________________________________________ Date of transaction ______________________ Original amount ______________ Amount owed presently _________________ Account No. __________________ Complete description of property ______________________________________ If an automobile, do you intend to keep making payments and keep the Vehicle? Yes ____ No ____. If any automobile, please supply Vin No. __________________________________________________________________ In who’s name is the debt? ____________________________________________ If you have more than one, please supply information on the back of this page, (Please be sure it is complete).
PLEASE READ THE FOLLOWING INSTRUCTIONS CAREFULLY
THE FOLLOWING PAGES ARE FOR YOUR LISTING OF UNSECURED CREDITORS, PLEASE INCLUDE THE FOLLOWING: 1. List creditors alphabetically. 2. Complete address including zip code is essential. 3. Below each creditor list the lawyer or collection agent who is collecting for the creditor. *Do not confuse the creditor with the collection agent. The collector works FOR the creditor. You owe the money to the creditor. If you do not list the creditor with the complete address he will not be notified of your bankruptcy and will not be discharged. 4. List the account number of the creditor and the collection agent or lawyer. 5. List the year the debt was incurred (and the month if incurred this year). 6. The purpose of the debt: loan, goods or services. 7. Whether you dispute the debt. 8. The amount owed. 9. Does the creditor have a title or a judgment against you. If so, please supply a copy of the summons or judgment.
Creditor, Account Number, Agency or attorney, name and address, account number if any , Alphabetical. Month & Year W(Wife) J(Joint) Goods, loan or services, Do you dispute the debt, Is there a Title or Judgment Against You
43. Do you owe any employees wages, salaries, commission, severance or sick leave? Yes ____ No ____/ 44. Do you owe any contributions to employee benefit plans? Yes ____ No ____ 45. Do any farmers or fisherman have claims against you? Yes ____ No ____ 46. Do you owe any deposits for purchase, lease or rental of your property or services that were not provided? Yes ____ No ____ 47. Do you owe any taxes to the Federal Government? Yes ____ No ____. If so, what amount and from what date? 48. Do you owe any money to the State Government? Yes ____ No ____. If so, what amount and from what date? ___________________________ ____________________________________________________________ 49. Do you owe any Municipal taxes? If so, what and when? _____________________________________________________________ 50. Do you have any executory contracts or unexpired leases? Yes ____ No ____ 51. Describe all contracts you hold now of any nature. Name and address, including zip code or other property: _______________________________________________________________ _______________________________________________________________ 52. Do you have any unexpired leases of real or personal property (including timeshare) Yes ____ No ____. If so, explain and include name and address of parties to the lease _______________________________________________ _________________________________________________________________
Describe the lease and the nature of your interest. (i.e., purchaser, agent, etc) _______________________________________________________________ Is the lease for non residential real property? Yes ____ No ____, If so, please Describe ________________________________________________________ Please state the contract number of any government contract: ________________________________________________________________ 53. Other than your spouse (if you are filing jointly), please list any other person or entity that is also liable on any debts y u have listed. If you are filing separately but you are married, please list the name and address of the non-debtor spouse. Name of co-debtor ________________________________________________ Address of co-debtor ______________________________________________ Name & address of creditor _________________________________________ ________________________________________________________________ SCHEDULE OF CURRENT INCOME 54. What is your marital status? (Check one) Single ____ Married ____ Separated ____ Divorced ____ Widow ____ 55. Please list below the names, ages and relationship of all your children and other dependents that you support: Name Age Relationship _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ 56. Are you currently employed? Yes ___ No ____. Name and address of your employer ___________________________________________________ _______________________________________________________________ Is your spouse employed? Yes ____ No ____ Name and address of Employer _______________________________________________________ ________________________________________________________________. 57. What is your occupation?___________________________________________ 58. What is your spouse’s occupation?____________________________________ 59. How long have you worked there? _____________________________________ 60. How long has your spouse worked there? ________________________________ CURRENT INCOME OF DEBTOR 61. Please state your MONTHLY income and expense from each source listed below. Debtor Spouse a. Gross Income Monthly ______________________________ b. Estimate monthly overtime ______________________________ Subtotal ______________________________ LESS PAYROLL DEDUCTIONS a. Payroll taxes & social security _______________________________ b. Insurance _______________________________ c. Union Dues _______________________________ d. Other (specify) _______________________________ Subtotal of payroll deductions _______________________________ TOTAL NET MONTHLY TAKE HOME PAY ___________________________
Regular income from operation of business or profession or farm (attach Detailed statement) __________________________________ Income from real property __________________________________ Interest and dividends __________________________________ Alimony, maintenance or support payments to the debtor for the debtor’s use or that of the dependents listed previously_________________________________ Social Security or other government assistance (specify) ___________________________________ Unemployment Benefits ___________________________________ Pension or retirement income ___________________________________ Other monthly income (specify) ___________________________________ Debtor Spouse TOTAL MONTHLY INCOME ____________________________________ TOTAL COMBINED MONTHLY INCOME ________________________________ 62. Describe any increase or decrease of more than 10% in any of the previous categories anticipated to occur within the year following the filing of this document. _________________________________________________________ __________________________________________________________________ __________________________________________________________________
CURRENT EXPENDITURE OF DEBTOR(S) COMPLETE THE FOLLOWING INFORMATION OF MONTHLY EXPENSES. 63. Does your spouse maintain a separate household? Yes ____ No ____ (this is applicable in joint bankruptcy) If so, please attach a separate page with a list of all of the spouse’s expenditures and label is “SPOUSE”. 64. What is your rent or mortgage payment ________________ 65. Are real estate taxes included? Yes ____ No ____. 66. Is property insurance included? Yes ____ No____ 67. What is your electric bill monthly? _________________ 68. What is your telephone bill monthly? _________________ 69. What is your water & sewer bill monthly? _________________ 70. What is your gas bill monthly? _________________ 71. What is your cable bill monthly? __________________ 72. Other (Specify) __________________ HOW MUCH DO YOU PAY MONTHLY FOR THE FOLLOWING: 73. Home maintenance __________________ 74. Food __________________ 75. Clothing __________________ 76. Laundry and dry cleaning __________________ 77. Medical and Dental __________________ 78. Transportation (not including car payments) __________________ 79. Recreation, clubs, newspapers, magazines, etc. __________________ 80. Charitable contributions __________________ 81. Insurance a. Homeowners/renters __________________ b. Life __________________ c. Health __________________ d. Auto __________________ e. Other __________________ 82. Taxes (not deducted from wages or included in home mortgage payments) __________________ 83. Installment payments a. Auto __________________ b. Other __________________ 84. Alimony, maintenance & support __________________ Payments for support of additional dependents not living at your home __________________ 85. Other __________________ TOTAL MONTHLY EXPENSES __________________ 86. If you are making car payments at this time, do you intend to keep the car and maintain payments? Yes ____ No ____. 87. Are there any other creditors you intend to keep paying in lieu of repossession? Yes ____ No ____. If so, whom: _____________________________________ __________________________________________________________________
88. State your gross income you have received since the beginning of this year until the commencement of this proceeding. (This is only from employment) ________________________________________________________________ Income from other sources __________________________________________ (Unemployment, AFDC, SSI, etc) Source ______________________________ 89. What was your gross income for last year?______________________________ What was your spouse’s? ___________________________________________ 90. What was your gross income for the year before last? _____________________ What was your spouse’s ____________________________________________ 91. What other income have your received in those years other than from your employment? (Please list the year and the person who earned the money and the amount). ______________________________________________________ _________________________________________________________________ 92. List any payments of more than $600.00 that you have made to any creditor in the 90 days preceding the commencement of this case Name & Address of Creditor Dates Amt. Paid Amt. Owed
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93. List any payments made within the past year immediately preceding the commencement of this case to or for the benefit of creditors who are or were insiders.___________________________________________________________ __________________________________________________________________ 94. List all suits which the debtor was a party within one year preceding the filing of this bankruptcy case. What is the caption of the suit? (Someone vs. Someone) _________________________________________________________________ Nature of the Proceeding (contract, tort, etc.) _________________________________________________________________ Name and Location of the Court _______________________________________ __________________________________________________________________ Docket No. ________________________________________________________ Disposition (pending, judgment, etc)___________________________________ Opposing attorney ________________________ Phone # ___________________ If you have the summons, please attach a copy. 95. Has any property been garnished within the past year? Yes ____ No ____. If so, please complete the following: Who is the creditor __________________________________________________ Address of creditor __________________________________________________ Caption of the suit __________________________________________________ Docket number ____________________ Court __________________________ Date garnished ________________________ Amount _____________________ Attorney’s name _______________________ Phone # _____________________
96. Has any of your property been repossessed within the past year immediately preceding the commencement of this bankruptcy? Yes ____ No _____. If so, please complete the following: Who is the creditor ______________________________________________ Address of creditor ______________________________________________ Date repossessed ________________________________________________ Description of Property ___________________________________________ Value of Property ________________________________________________ 97. Has any of your property been sold at a foreclosure sale: Yes ____ No ____ If so, please state date, description and value ___________________________ _______________________________________________________________ 98. Is any of your property in the hands of a receiver? Yes ____ No ____. If so, explain __________________________________________________________ 99. Have you turned over or assigned any of your property to a creditor within the last 120 days? Yes ____ No ____. If so, explain ____________________________ __________________________________________________________________ 100. Have you made any gifts, other than the usual presents to family members and charitable donations, during the last year? Yes ____ No ____. If so, explain __________________________________________________________________ 101. Have you suffered any losses from fire, theft or other casualty or gambling within the past year? Yes ____ No ____. 102. Were any of your losses covered in full or part by insurance? Yes ____ No ____ If so, explain _______________________________________________________
103. Have you paid any money or transferred property to anyone, including attorneys, for a consultation or preparation of bankruptcy? (other than the filing fee you gave to me). Yes ____ No ____ 104. Have you made any transfer, whether as a sale or for security of your property during the last year? Yes ____ No ____. If so, explain__________________ ________________________________________________________________ 105. List any accoaunts (checking savings, etc) which were closed, sold or transferred in the past year. Name of Institution _________________________________________________ Complete address __,________________________________________________ ,60; Type of account ____________________________________________________ Amount of Final Balance ___________________ Date closed _______________ In who’s name? ____________________________________________________
Name of Institution _________________________________________________ Complete address ___________________________________________________ Type of account _________________________ Number __________________ Amount of Final Balance _______________ Date closed __________________ In who’s name? ____________________________________________________
106. Have you had any safe deposit boxes or depositories in the past year? Yes ____ No ____. If so, please complete the following: Do you still have the box? Yes ____ No ____ Name of Bank _____________________________________________________ Address of Bank ___________________________________________________ Name(s) and address(es) of authorized persons with access to box or depository. _________________________________________________________________ _________________________________________________________________
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