INSTRUCTIONS: Bankruptcy is a court procedure which ...



BANKRUPTCY NOTES TO CLIENT, Q AND A and WORKSHEET

(PLEASE SAVE THIS DOC TO YOUR COMPUTER AS “LAST NAME_FIRSTNAME-BKWORKSHEET”)

You must initial each Note and at the bottom of Q&A indicating you have read the information.

NOTES:

1) YOU MUST HAVE A VALID DRIVER’S LICENSE AND GOVERNMENTAL PROOF OF SOCIAL SECURITY NUMBER (IF YOUR SOCIAL IS NOT ON YOUR LICENSE) _______

2) Please dress appropriately for a court proceeding–no shorts, flip flops, ragged clothes, or gum _

3) You must show up 10 minutes prior to your hearing – Bankruptcy trustees don’t wait. ______

4) If you get a letter from the trustee requesting info, read it carefully and send info to them if asked

QUESTIONS AND ANSWERS

If I hire you to file my bankruptcy, am I safe from bank or wage attachment/garnishment? No. If you have a judgment against you, the creditor may garnish your wages and/or your bank accounts any time before your bankruptcy is filed and you have a case no. (Also see other notes re: checking account) _______

I am a cosigner for a debt, how does bankruptcy affect my obligation? If the debt is a dischargeable debt then you will not have to pay it. However, the cosigner will become primarily responsible for the debt. Be sure to list the co-signer as a creditor in your schedules as they may have a contingent claim against you.

Can I keep my house after bankruptcy? Depending upon which exemption scheme is selected and your circumstances, you may exempt up to $20,200 per owner in equity, To determine your equity, you need to know the approximately what your house would sell for at a reasonably quick sale. Once you know the value, subtract the amount owed to all mortgages and liens plus selling and transfer costs. If you keep your house after, remember to make your house payments on time after bankruptcy. You have the option of reaffirming but this will re-obligate you on the loan. If you do not reaffirm, you may generally keep paying and still keep your house. If your circumstances later change and you cannot afford your house anymore, you would be able to walk away. If you later refinance your home, keep in mind that you will lose the ability to be able to walk away from your house without owing. (Note: you will be responsible for maintaining the exterior of your home in compliance with city ordinances until the home has been sold – this could take 1 ½ - 2 ½ years – and sometimes more – depending on where your live and other factors) Also be wary of refinance companies who tell you not to pay while they process your new loan. They may change the interest rate at the last moment

Can I keep my car after bankruptcy? You are allowed to have $3000.00 equity in a vehicle, whether it is paid off or you owe less than the car’s value. There is an additional $1,100.00 wild card exemption which also may be applied to your vehicle allowing you to keep a car worth $4,100.00. If you have payments on your vehicle, you will also have to make timely payments after your bankruptcy is filed. (Also See “Reaffirmation Agreements”). If you use your vehicle in your employment or own business, you may be able to apply some or all of the exemption for tools of trade ($2025.00)

Can I keep my credit cards after bankruptcy? Under some circumstances you may keep your credit cards. There are many factors which must be considered. Some of those include the credit card balance at the time of the bankruptcy, what the credit card company is willing to do and your ability to pay the present and future credit card debt. Normally, a credit card company will not negotiate with you to allow you to keep it if you owe less than $300; however, if you owe more than $500, the attorney may not agree that it is in your best interests to reaffirm.

Will bankruptcy affect my checking account? If you are behind on a debt to the same bank where you have your credit card, the bank may “set off” any money in your checking account (This is by contract between you and the bank). After you have filed your bankruptcy, the bank will not be allowed to set off any funds on deposit, however, they make close your checking account, if this is their policy. If you choose to keep your checking account at that bank or credit union, be careful to assure that your account is still open prior to writing any checks. Also, if you have a judgment against, any checking account is subject to garnishment prior to your bankruptcy. Any funds in the account will be taken plus bank fees.

Will I lose my job? No. Bankruptcy laws prohibits discrimination based upon a debtor filing for protection under the bankruptcy laws.

Will my employer find out about my bankruptcy? Under normal circumstances, unless your employer is a creditor, your employer will not know. In a Chapter 13 the employer will know as a wage order is mandatory.

Will bankruptcy stop a wage attachment? Yes., but you have to have reviewed and signed all the final documents and verify that you have a case number. If you have a garnishment pending, it is important to let the attorney know.

Will bankruptcy stop a judgment? Yes. Most civil judgments are stopped by bankruptcy; however if you own property and the creditor has filed a ‘judgment lien, there are additional steps which must be taken to remove the lien, if it is even possible – See below Questions

Will a bankruptcy remove a lien? Under some circumstances once the bankruptcy proceedings have started, a special motion can be filed to remove certain liens. It will take a bankruptcy court order to remove them. Normally, it is the Debtor’s burden to prove that there is not equity in the property after deducting the exemption. This is a complicated area of the bankruptcy law and requires additional attorney’s fees.

Will bankruptcy stop an eviction action? Generally not. You will be able to discharge any amounts you owed up until the bankruptcy was filed, including your obligation under a lease contract; however you may be legally obligated for the rental value if you remain on the property after your case is filed.

Will bankruptcy stop a foreclosure?

Yes. However, a home is an asset usually secured by a mortgage deed (or deed of trust). The mortgage company is entitled apply to the court for relief from the automatic stay, the order preventing creditor action by virtue of the bankruptcy. Depending upon several factors, you may be able to prolong a foreclosure until you have received your discharge from bankruptcy. Usually, to keep a home that is in foreclosure you will have to make a deal with the note holder or enter into a Chapter 13 bankruptcy where you pay back the arrearages through the trustee in monthly payments and continue to timely make your current mortgage payments.

I am divorced, will bankruptcy wipe out my obligation to pay joint debts? As between you and the creditor, you will be discharged from all dischargeable joint debts. However, you should discuss this with your family law attorney to understand the other implications of the filing of a bankruptcy during the pendency of a dissolution action or divorce case, and if you may be liable to your ex-spouse for a prior court ordered debt and potentially held in contempt of divorce court. Also, remember that if you are discharged from joint debts, your ex-spouse is responsible for the entire balance owing on the debt. The action may be brought into bankruptcy court to determine if the debt was really “in the nature of” spousal support and therefore not dischargeable. DON’T FORGET TO LIST YOUR EX-SPOUSE ON YOUR BANKRUPTCY.

Are there any debts that I can't wipe out in bankruptcy? Yes, there are certain debts that are NOT dischargeable in bankruptcy. Generally speaking, the following debts will not be discharged: (Taxes see next paragraph); Spousal and Child Support; Debts arising out of willful misconduct and or malicious misconduct by the debtor; liability for injury or death from driving while intoxicated; non dischargeable debts from a prior bankruptcy; student loans and criminal fines, penalties and forfeitures. Those debts which are secured will be discharged, however, expect the creditor to take the necessary legal steps to take back the property in the event you quit paying for it. In most cases the debtor may retain the property by redemption, reaffirmation, or sometimes just continuing to pay.

Redemption is generally used when you owe more money than the car is worth or if you owe approximately what it is worth but are so far behind in payments that you cannot afford to get caught up. In a redemption, you may force the creditor to accept the ‘value’ (what you could sell the car for at approximately retail sale price) in one lump sum. If you do not have the cash (which you probably don’t if it’s worth more than $1000.00 or so, or you cannot borrow the money from a friend or relative, you may call the 711 Redemption Corp. at (888) 721-2800 to see if they can help you. Generally they require 1) 2 years employment at the same company or 5 years at roughly the same rate if you changed jobs in the past two years, 2)enough income (?50% of your income cannot exceed housing and vehicles), 3) no prior repossession in past 5 years, and 4) no discharge of a Star Bank debt. They charge a high interest rate; however, if the net result is a savings then your decision should be based on that.

Reaffirmation is when the debtor signs re-signs the original note, usually with no modifications in the terms. In practice, if you have a Non Purchase Security Interest in goods which you have pledged for a loan (that you already owned), or to a slightly lesser extent with Purchase Money Security Interests (when you buy a computer or other appliance or furniture at a store and use the money to make the purchase), you may reaffirm with payments for a smaller balance and smaller payments. This does not happen with vehicles.

A lot of times people may continue to pay and the creditor will not bother them. They cannot call you in any event. If you are late however, all they can do is pick up the secured item (usually your car)

Income taxes may be discharged if they are due for more than 3 tax years prior t the last year due plus any time periods where the IRS agreed not to collect from your, and the taxes were properly filed. There are other rules – you must contact the attorney.

Disclaimer: This information deals with Chapter 7 consumer bankruptcy. The information contained in the QandA is provided for general information purposes only and is not intended to be a legal opinion nor legal advice nor is it intended to be a complete discussion of all the issues related to the area of Chapter 7 consumer bankruptcy. Every individual's factual situation is different and you should discuss your specific situation with the attorney.

Put your initials here indicating you’ve read the above: _______________

What’s Next?

After you complete these forms and email or drop them off to me and you are paid in full, follow up in a couple of days to get a time to come in and thoroughly review and sign all of the paper work. This must be done before filing. There is a special form you must sign to allow your case to sent electronically. You cannot get a case number until this is done. Your meeting will take between 30 minutes and 1 ½ hours depending on how thoroughly you answer the questions on the form you submit. (It is important that you at least estimate the dates when you incurred your debts because it can take a long time for me to ask you each one individually and wait while you try to remember)

And Next After Signing?

After your case has been filed, you will receive a notice in the mail. After you receive the notice, you need to leave a message for me indicating that you know when and where to go.

One to two days prior to your hearing, please call me one more time letting me know you will be at the hearing.

Your hearing will be located at 201 Superior Ave., Cleveland, OH . This is the building just west of the Cleveland Public Library (on the other side of E. 3rd) and across from the BP building. This is just east off public square. You will need to go through a metal detector and then to the 6th floor.

There is a “Notice to debtors and counsel’ form along the wall when you walk in. You must read this form before your case is called.

What is the hearing like?

A trustee will ask you questions about your answers to the questions on the bankruptcy forms we provided to the Court. His primary concern is whether you have an asset that is not exempt (meaning there is a law that allows you to keep it) or that is not encumbered (you owe enough money on it so that there is no non-exempt equity). He also wants to ensure that you have not given anything major item away in the past year and that you understand that if you inherit something in the next six months you have to notify him. Normally the hearing takes 3-5 minutes. Several cases are called into a room at one time. You have a better chance than not that you will be able to watch at least one case proceed ahead of yours. You should listen carefully to the questions and try to answer the question with no unnecessary extra explanation. If you appear too nervous, the may get frustrated and reschedule your case. He may think you are trying to hide something if you appear too nervous or are unable to answer the questions, so . . get a good night’s sleep and don’t worry about it. You don’t want to create the problem you are trying to avoid. If there are any problems with your case, I will have discussed this with you prior to filing.

If you expect a large refund next year YOU MUST BRING THIS TO MY ATTENTION ASAP.

INSTRUCTIONS: Bankruptcy is a court procedure which requires detailed financial information. Please complete this questionnaire as accurately and completely as possible. Typing directly from the computer or printing is preferable. Your bankruptcy petition will be prepared according to the information that you provide. If you have any questions on any item, place a checkmark in the margin and be sure to ask the question when you return the form. If your answer is too long for the space provided, mark with * and write the additional information on a separate page. If you and your spouse are filing for bankruptcy, you should fill out this form together. You must provide all of the information requested or we will not be able to help you. Answer all questions even if they do not apply. Write None or N/A for Not Applicable.

PART I-GENERAL INFORMATION

NOTE: IF YOU ARE MARRIED AND LIVING WITH SPOUSE WHO IS NOT FILING, YOU STILL MUST LIST SPOUSE’S GENERAL INFO AND INCOME AND EXPENSES UNDER BUDGET SECTION BUT DO NOT LIST ASSETS OR DEBTS WHICH BELONG SOLELY TO YOUR SPOUSE. List spouse’s second insame order as names

Is Spouse filing too? Y N__

Date completed: ____________________  Referred By: _______________________________________________________

Your Name: All names used in past 6 years: Spouse(ifany)

Social Security No.: ____________________ Spouse’s SS     Birth Dates: _____________/_______

Address: County

Tel #/times: Home: ( )Work: ( )cell:__________Other:

Spouse addr: County

Sp Tel #/times: Home: ( )Work: ( )cell:__________Other:

part iI-assets

INCLUDE ALL ITEMS OF PROPERTY ON THIS LIST INCLUDING CARS, HOUSES, COMPUTERS, ETC. EVEN IF YOU OWE MONEY ON THEM. YOU WILL ALSO LIST THE DEBT FOR THESE ITEMS ON A SEPARATE LIST OF DEBTS/CREDITORS.

IMPORTANT NOTE: MOST PROPERTY ITEMS WILL HAVE AN “EXEMPTION” (LAW ALLOWING YOU TO KEEP CERTAIN ITEMS TO GIVE you’re a FRESH START) . IN ORDER TO HAVE AN EXEMPTION YOU MUST!!! LIST THE ASSET. IF YOU FAIL TO LIST AN ITEM THAT WOULD HAVE BEEN EXEMPT FROM ATTACHMENT YOU WILL NOT BE ALLOWED TO LATER TRY TO APPLY THE EXEMPTION AND YOU WILL LOSE WHATEVER ASSET YOU FAILED TO LIST/ TRUSTEE’S HAVE ACCESS TO A LOT OF INFORMATION. IF YOU LIST AN ITEM WHICH IS NOT EXEMPT I WILL DISCUSS THE MATTER BEFORE YOU FILE. IF YOU HAVE A QUESTION ABOUT AN ITEM MAKE SURE YOU ASK ME.

ENTER YOUR INITIALS INDICATING YOU HAVE READ THE ABOVE NOTICE _________________

 

INSTRUCTIONS: Please fill out the following list of assets. The term “market value” means what you would be able to sell the item for in its present condition. It does not mean what you originally paid for the item. If you own real estate, we must have a copy of the legal description and permanent parcel number of the property. This information can usually be located on your deed to the property and describes the actual physical boundaries of the land. You must list all vehicles, real estate, motorcycles, etc., even if you are making installment payments on the assets. If filing jointly, please note WHO HOLDS TITLE TO THE ASSET (YOU WILL LIST WHO IS OBLIGATED ON DEBT SEPARATELY ON LIST OF DEBTS)

Your home/Real Estate: (INCLUDES THE HOME YOU LIVE IN EVEN THOUGH YOU OWE THE BANK)

Address:___________________________Date Purchased: ___  Market Value: $______ Describe improvements_________

Bal.1st mortgage$____Name of creditor ____________________(be sure to list name/address/account info in Part V)/Mnthly payment$ ____

2nd Mortg Bal., if any $_______/Name of creditor _____________________________Monthly payment $________

3rd Mortg Bal., if any $_______/Name of creditor______________________________Monthly payment $________

If married, to whom is the property titled? ___H, ___W, ___Jt & describe any changes/transfers to the title in the past 10yrs?_____________

Do you own any other real estate, including camping lots, Vacant Lots, Out-of-Town Property, Etc.? YES____NO_____

Address: Date Purchased: ___   Bal owed$_____     Market Value:$_______

For additional real property – list here & attach separate page, if necessary:____________________________________________

Cash On Hand:$ __________

 

Bank Accounts (include all accounts checking and savings, or credit union):H=Husband, W=Wife, Jt=Joint(applies to joint cases only)

1)Name of Bank: _________________________  check one         checking___ savings ___credit union__ H___,W___,Jt___

Amount in account: _____________________           Account number: ___________________

2)Name of Bank: _________________________           checking___, savings____,credit union____ H___,W___,Jt__

Amount in account: _____________________           Account number: ___________________

3)Name of Bank: _________________________           checking___ savings____credit union____ H___W___Jt__

Amount in account: _____________________           Account number: ___________________

Security Deposits: with landlord: $_______ H, ___W, ___Jt ,$_________ H, ___W, ___Jt

with utility company:1)_________________, $_______ H, ___W, __Jt , 2)__________________$_________ H, ___W, ___Jt __

  

Property owned by you List major items (eg.living room set, dining room,etc. estimate garage sale value

Household goods and furnishings itemize: $____________________

Collections of art, stamps, coins, etc: $____________________

Wearing Apparel:  $____________________

Jewelry:   H, ___W, __Jt $____________________

Guns, sporting equip: H, ___W, __Jt $____________________

Retirement plans/Pensions/401ks/IRA’s (you must list these- you will only lose it if you forget to list it)

Name type est. current value$____________________

Name___________________________ type est. current value$____________________

Debts owed to you (NEXT YEAR’S tax refund /judgments you have against someone, etc.)

Do you have any possible law suits against any person or company for any thing at all? $____________________

Does any person or entity owe you any money or compensation for anything?____________________________________

Ownership/Stock in any company(C/SCorp/publicly traded)(if you are self-employed list the name you use or self-employed, if no name, note if 1099?

Trade Name/addr of unincorporated self-employment __H, __W, __Jt

Name Number of shares% _______ Value per share$___________________ __H, __W, __Jt

Name Number of shares% _______ Value per share$___________________ __H, __W, __Jt

Interests in any partnerships?

Name ____________________Ownership% _______ value $_______________

Insurance policies (List polices through work and otherwise-find out if a relative bought a policy in your name-list loan payment address on creditor section)

1)Company ____________________   Owner Name ______________ Beneficiary/relationship___________________

Is there any cash which you can take or borrow against during your life? ___Yes___No, If so, total value $__________

And do you have a loan out on it now? (If your policy has cash value you MUST inform me or you will lose it)

1)Company ____________________   Owner Name ______________ Beneficiary/relationship___________________

Is there any cash which you can take or borrow against during your life? ___Yes___No, If so, total value $__________

And do you have a loan out on it now? (If your policy has cash value you MUST inform me or you will lose it)

Annuities?-describe _________________________________________________________ $____________________

Do You have:

A potential inheritance, or a relative about to die from whom you expect money? Yes__ No___, est. value $________

Livestock, Farm animals-est. value $______Farming equipment-est. value $______Office equipment, furnishings &supplies est. value $______Machinery, Fixtures and supplies - est. value $________; Inventory  - est. value $________Patents, Copyrights, Franchises $____________________ est. value $________Government or corporate bonds est. value $________

Automobiles, trucks, motorcycles, boats, etc. (List cars whether paid for or not and indicate whether leased

**** DON’T FORGET TO ALSO LIST ANY DEBT YOU OWE, the account # and address FOR THE CAR ON THE SCHEDULE OF DEBTS EVEN IF YOU ARE PLANNING ON KEEPING YOUR CAR!) If married,

Year/Make&fullModel/Style fmv value amt. owed yrs left-if leased Creditor name mileage condition Keeping?Y/N H/W/J

/ /   $ $

/ /   $ $

/ /   $ $

PART III - INCOME AND BUDGET INFORMATION-Part III-A- Income

List info for spouse unless they do not live with you and are not filing. Be sure to NOTE IF deductions only occur on one paycheck per month (like union dues or parking). ATTACH YOUR PAY CHECK STUBS PLEASE. If income varies, average.

List all income with how often you are paid: WEEKLY, BI-WEEKLY (EVERY OTHER WEEK)-THERE ARE 26 BI-WEEKLY PERIODS IN ONE YEAR, SEMI-MONTHLY (THE FIRST AND 15TH OF THE MONTH USUALLY – THESE PAY CHECKS WILL NOT LAND ON THE SAME DAY OF THE WEEK) –THERE ARE 24 SEMI-MONTHLY PERIODS IN ONE YEAR. DO NOT MULTIPLY YOUR PAYCHECK BY 2 OR 4 TO GET THE MONTHLY AMOUNT.

Marital Status: place X on line PLEASE ATTACH THE LAST SIX PAY STUBS IF AVAILABLE.

(Single)  ___   (Married) ___    (Divorced)   ___    (Separated)  ____    (Widowed) __

Dependents: list all children – make a note if someone else may claim child on taxes).Marital Status:

Name: __________________ Age: __ Relationship:______ /Name: ____________________ Age __ Relationship:_______

Name: __________________ Age: __ Relationship:______ /Name: ____________________ Age __ Relationship:_______

Name: __________________ Age: __ Relationship:______ /Name: ____________________ Age __ Relationship:_______

Occupation/job title: Client how long? Spouse’s how long?

Employer’s Name: Spouse’s

Employer’s Addr: Spouse’s

How often do get paid? wk-__ |bi-wkly-___| semi-monthly-__|monthly__Spouse wk-__| bi-wkly-__| semi-mnthly-__| monthly-__

Gross amount of each check   base$_________avg. OverTime/ck $____ Spouse base$_________avg. OverTime/ck $

  Deductions for Taxes/Social Security/Medical Debtor $______Spouse $______ job 2 Debtor $______Spouse $______

  Deductions for Insurance Debtor $______Spouse $_______ job 2 Debtor $______Spouse $______

  Deductions for Union Dues Debtor $______Spouse$_______ job 2 Debtor $______Spouse $______

  Deductions for Child Support/Alimony Debtor$______ Spouse $_______ job 2 Debtor $______Spouse $______

  Other Deductions (Describe) _______per ck? Debtor $______Spouse______ $___________

 Net Pay (Amount You Bring Home/pay) Debtor $______ Spouse $_______ JOB 2: Debtor $______ Spouse $_______

 OTHER INCOME 1$____ PER __(wk, ,mo, bi-wkly, semi-mnthly), Source:____________________ debtor___ spouse__

 OTHER INCOME 2$____ PER __(wk, ,mo, bi-wkly, semi-mnthly), Source:____________________ debtor___ spouse__

 OTHER INCOME 3$____ PER __(wk, ,mo, bi-wkly, semi-mnthly), Source:_________________ __ debtor___ spouse__

(Part III-B) Monthly expenses (IF the bill is every 3 months or bi-weekly please divide or write /3 mos)

NOTE: DO NOT LIST EXPENSES DEDUCTED FROM YOUR CHECK & LISTED UNDER INCOME ABOVE EG, INSURANCE/CHILD SUPPORT

 Rent____ or Mortgage Payment_____   $______Does it include Real Estate taxes? yes__ No__Insurance? yes___ No____

Utilities: Electricity and Gas   $_____Water and Sewer   $_______Telephones $____Cable   $____Other ________ $

Home Maintenance (Repairs and Upkeep)                                                                     $____________________

Food  per month                                                                                                             $____________________

Clothing                                                                                                              $____________________

Laundry and Dry Cleaning                                                                                                 $____________________

Medical and Dental Expenses                                                                                            $____________________

Transportation (Gas, Maintenance and Repair)                                                           $____________________

Entertainment, Recreation, Newspapers                                                                          $____________________

Charitable Contributions                                                                                                    $____________________

Insurances:  Homeowner’s or Renter’s   $_____Life  $____Health $____, Auto$____ Total $____________________

DO NOT LIST INSURANCE INCLUDED IN HOUSE PAYMENT ABOVE OR DEDUCTED FROM PAY CK.

Taxes (if not included in payroll) describe ______________________________________ $____________________

Auto Payment or Auto Lease (List Each If More than One)                                        $____________________

Alimony or Child Support  (NOT DEDUCTED FROM PAY CHECK)                         $____________________

Other: ________  Personal Care ____________________________________ Total $____________________

Expenses from Operation of a Business (Attach a Detailed List)                               $____________________

 Total Monthly Expenses                   $____________________

PART IV - FINANCIAL AFFAIRS INFORMATION

PART IV-a –Past Income and address questions

Total income earned in the last two years (from working):

CURRENT year to date:/through what date? PAST YEAR: 2 YEARS AGO Were tax returns filed for past 3 years?

Client: $_______ ___/___/___ $_______ $_______ (YES)  _____ (NO) _______

Spouse: $_______ ___/___/___ $_______ $_______ List years not filed _____________

Did you receive, or are you entitled to, a state or federal tax refund? NO__ YES__,amount: $_______, rec’d date________

Do you expect any changes to your refund for the next year? NO__ YES__ (Did you marry this past year or have a child or support another’s child or have a child leave your household?)Explain:

List all other income by source for you or your spouse for past two years (separate by year) include Social Security, Pension payments which are in pay-out status (retired or disabled), IRA or 401K money which you cashed in, Unemployment, Alimony, Child Support, Rental Property, Dividends, Interest, Etc.? NO__ YES__ List source and amount:

List any names for you or spouse (if filing) used within the last six years? NO__ YES__: names:

List all prior addresses for the past two years:

From: _______     to: _______ @ 

From: _______     to: _______ @ 

From: _______     to: _______ @   _

PART IV -b – OTHER IMPORTANT QUESTIONS

INSTRUCTIONS: Please provide all pertinent information for each yes answer. This information should include names, dates, amounts involved and case numbers. Answer all questions. Enter No if applicable.

Have you:(Please give Names,dates, addr,Case No.,etc. under ‘Describe’ for yes answers)

paid any creditor more than $600 total in the last 90 days? excluding mortgage or auto payments

____________________________________________________________________________________________________

paid any relatives or friends any money in the last year? No___ Yes____, Describe

_______________________________________________________________________________________________

been a party in any lawsuits in the last year? Been sued in the last year? Or sued anyone? No___ Yes____, Describe

____________________________________________________________________________________________________

been garnisheed or had any bank attachment in the last year? No___ Yes____, Describe

________________________________________________________________________________________________

had any repossession or foreclosures in the last year? No___ Yes____, Describe

given any property to a creditor in the last four (4) months? No___ Yes____, Describe

Have you been in a receivership in the last year? No___ Yes____, Describe

Have you given away any large gifts in the last year? No___ Yes____, Describe

Did you suffer any losses from fire, theft or gambling in the last year? No___ Yes____, Describe

Have you paid anyone for debt counseling in the last year? No___ Yes____, Describe Have you sold, transferred or given away anything of value in the last year (other than in your business?) No___ Yes____, Describe

Have you closed any bank accounts in the last year – checking or saving? No___ Yes____ ,Describe

Name of Pre-Credit Counseling Co. Amt Paid $ Amt paid attorney

Do you have or did you have a safe deposit box, or access to one, in the last year? No___ Yes____ ,Describe

____________________________________________________________________________________________________

Has any bank(s) taken any money from your accounts in the past 90 days to pay a debt? No___ Yes____,Describe

________________________________________________________________________________________________

Are you holding any property belonging to someone else? No___ Yes____ ,Describe

Were you in business for yourself or involved in a partnership in the last four (4) years? No___ Yes____ ,Describe

If yes call me for business questionnaire

Please write any other notes or concerns or information about your financial situation that was not asked:

PART V - Schedule of debts

 INSTRUCTIONS: In order for a debt to be discharged in bankruptcy, it must be correctly listed on the bankruptcy forms. The info that you provide will be used to complete the official bankruptcy forms. It is important, therefore, that you accurately list every possible debt, even those that you dispute or deny owing, and debts to friends and relatives. IF YOU DON’T KNOW THE BALANCE, GUESS(and write approx.)List any co-signer as a creditor in addition to notating which debt is co-signed–this includes ex-spouse.

PLEASE LIST HOUSE FIRST (IF ANY), THEN CARS, AND ANY OTHER SECURED DEBTS, THEN TAXES, then unsecured debts (like credit cards, personal loans, medical bills, paycheck loans etc.) If you need more pages, copy or attach same info on separate page.

LIST ORIGINAL CREDITOR UNLESS YOU ARE SURE THEY DEBT WAS SOLD TO AN ACQUISITION CO. If so, list the company who now owns the debt and put the original creditor and acct # in parentheses. Err on the side of listing both the original creditor and the latest collection company.

Creditor____________________________________Address:

City: ST ZIP - Account number:

Balance: $________Check one: Loan ___ credit purchases ____ cash advance ____ medical____ utility ____ other___

Date opened: _____ last used _____Approx. date range bulk of debt incurred: (Please enter your best guess)

If married, please check: H__, W__, J__; Any co-signers? NO__ YES__ Name & address: __________________________

Describe collateral, if any (eg. car, household goods pledged for loan, or house):

Most recent Collection agency/attorney:

Address: City: ST ZIP -

Creditor____________________________________Address:

City: ST ZIP - Account number:

Balance: $________Check one: Loan ___ credit purchases ____ cash advance ____ medical____ utility ____ other___

Date opened: _____ last used _____Approx. date range bulk of debt incurred: (Please enter your best guess)

If married, please check: H__, W__, J__; Any co-signers? NO__ YES__ Name & address: __________________________

Describe collateral, if any (eg. car, household goods pledged for loan, or house):

Most recent Collection agency/attorney:

Address: City: ST ZIP -

Creditor____________________________________Address:

City: ST ZIP - Account number:

Balance: $________Check one: Loan ___ credit purchases ____ cash advance ____ medical____ utility ____ other___

Date opened: _____ last used _____Approx. date range bulk of debt incurred: (Please enter your best guess)

If married, please check: H__, W__, J__; Any co-signers? NO__ YES__ Name & address: __________________________

Describe collateral, if any (eg. car, household goods pledged for loan, or house):

Most recent Collection agency/attorney:

Address: City: ST ZIP -

Creditor____________________________________Address:

City: ST ZIP - Account number:

Balance: $________Check one: Loan ___ credit purchases ____ cash advance ____ medical____ utility ____ other___

Date opened: _____ last used _____Approx. date range bulk of debt incurred: (Please enter your best guess)

If married, please check: H__, W__, J__; Any co-signers? NO__ YES__ Name & address: __________________________

Describe collateral, if any (eg. car, household goods pledged for loan, or house):

Most recent Collection agency/attorney:

Address: City: ST ZIP -

Creditor____________________________________Address:

City: ST ZIP - Account number:

Balance: $________Check one: Loan ___ credit purchases ____ cash advance ____ medical____ utility ____ other___

Date opened: _____ last used _____Approx. date range bulk of debt incurred: (Please enter your best guess)

If married, please check: H__, W__, J__; Any co-signers? NO__ YES__ Name & address: __________________________

Describe collateral, if any (eg. car, household goods pledged for loan, or house):

Most recent Collection agency/attorney:

Address: City: ST ZIP -

Creditor____________________________________Address:

City: ST ZIP - Account number:

Balance: $________Check one: Loan ___ credit purchases ____ cash advance ____ medical____ utility ____ other___

Date opened: _____ last used _____Approx. date range bulk of debt incurred: (Please enter your best guess)

If married, please check: H__, W__, J__; Any co-signers? NO__ YES__ Name & address: __________________________

Describe collateral, if any (eg. car, household goods pledged for loan, or house):

Most recent Collection agency/attorney:

Address: City: ST ZIP -

Creditor____________________________________Address:

City: ST ZIP - Account number:

Balance: $________Check one: Loan ___ credit purchases ____ cash advance ____ medical____ utility ____ other___

Date opened: _____ last used _____Approx. date range bulk of debt incurred: (Please enter your best guess)

If married, please check: H__, W__, J__; Any co-signers? NO__ YES__ Name & address: __________________________

Describe collateral, if any (eg. car, household goods pledged for loan, or house):

Most recent Collection agency/attorney:

Address: City: ST ZIP -

Creditor____________________________________Address:

City: ST ZIP - Account number:

Balance: $________Check one: Loan ___ credit purchases ____ cash advance ____ medical____ utility ____ other___

Date opened: _____ last used _____Approx. date range bulk of debt incurred: (Please enter your best guess)

If married, please check: H__, W__, J__; Any co-signers? NO__ YES__ Name & address: __________________________

Describe collateral, if any (eg. car, household goods pledged for loan, or house):

Most recent Collection agency/attorney:

Address: City: ST ZIP -

Creditor____________________________________Address:

City: ST ZIP - Account number:

Balance: $________Check one: Loan ___ credit purchases ____ cash advance ____ medical____ utility ____ other___

Date opened: _____ last used _____Approx. date range bulk of debt incurred: (Please enter your best guess)

If married, please check: H__, W__, J__; Any co-signers? NO__ YES__ Name & address: __________________________

Describe collateral, if any (eg. car, household goods pledged for loan, or house):

Most recent Collection agency/attorney:

Address: City: ST ZIP -

Creditor____________________________________Address:

City: ST ZIP - Account number:

Balance: $________Check one: Loan ___ credit purchases ____ cash advance ____ medical____ utility ____ other___

Date opened: _____ last used _____Approx. date range bulk of debt incurred: (Please enter your best guess)

If married, please check: H__, W__, J__; Any co-signers? NO__ YES__ Name & address: __________________________

Describe collateral, if any (eg. car, household goods pledged for loan, or house):

Most recent Collection agency/attorney:

Address: City: ST ZIP -

Creditor____________________________________Address:

City: ST ZIP - Account number:

Balance: $________Check one: Loan ___ credit purchases ____ cash advance ____ medical____ utility ____ other___

Date opened: _____ last used _____Approx. date range bulk of debt incurred: (Please enter your best guess)

If married, please check: H__, W__, J__; Any co-signers? NO__ YES__ Name & address: __________________________

Describe collateral, if any (eg. car, household goods pledged for loan, or house):

Most recent Collection agency/attorney:

Address: City: ST ZIP -

Creditor____________________________________Address:

City: ST ZIP - Account number:

Balance: $________Check one: Loan ___ credit purchases ____ cash advance ____ medical____ utility ____ other___

Date opened: _____ last used _____Approx. date range bulk of debt incurred: (Please enter your best guess)

If married, please check: H__, W__, J__; Any co-signers? NO__ YES__ Name & address: __________________________

Describe collateral, if any (eg. car, household goods pledged for loan, or house):

Most recent Collection agency/attorney:

Address: City: ST ZIP -

Creditor____________________________________Address:

City: ST ZIP - Account number:

Balance: $________Check one: Loan ___ credit purchases ____ cash advance ____ medical____ utility ____ other___

Date opened: _____ last used _____Approx. date range bulk of debt incurred: (Please enter your best guess)

If married, please check: H__, W__, J__; Any co-signers? NO__ YES__ Name & address: __________________________

Describe collateral, if any (eg. car, household goods pledged for loan, or house):

Most recent Collection agency/attorney:

Address: City: ST ZIP -

Creditor____________________________________Address:

City: ST ZIP - Account number:

Balance: $________Check one: Loan ___ credit purchases ____ cash advance ____ medical____ utility ____ other___

Date opened: _____ last used _____Approx. date range bulk of debt incurred: (Please enter your best guess)

If married, please check: H__, W__, J__; Any co-signers? NO__ YES__ Name & address: __________________________

Describe collateral, if any (eg. car, household goods pledged for loan, or house):

Most recent Collection agency/attorney:

Address: City: ST ZIP -

Creditor____________________________________Address:

City: ST ZIP - Account number:

Balance: $________Check one: Loan ___ credit purchases ____ cash advance ____ medical____ utility ____ other___

Date opened: _____ last used _____Approx. date range bulk of debt incurred: (Please enter your best guess)

If married, please check: H__, W__, J__; Any co-signers? NO__ YES__ Name & address: __________________________

Describe collateral, if any (eg. car, household goods pledged for loan, or house):

Most recent Collection agency/attorney:

Address: City: ST ZIP -

Creditor____________________________________Address:

City: ST ZIP - Account number:

Balance: $________Check one: Loan ___ credit purchases ____ cash advance ____ medical____ utility ____ other___

Date opened: _____ last used _____Approx. date range bulk of debt incurred: (Please enter your best guess)

If married, please check: H__, W__, J__; Any co-signers? NO__ YES__ Name & address: __________________________

Describe collateral, if any (eg. car, household goods pledged for loan, or house):

Most recent Collection agency/attorney:

Address: City: ST ZIP -

Creditor____________________________________Address:

City: ST ZIP - Account number:

Balance: $________Check one: Loan ___ credit purchases ____ cash advance ____ medical____ utility ____ other___

Date opened: _____ last used _____Approx. date range bulk of debt incurred: (Please enter your best guess)

If married, please check: H__, W__, J__; Any co-signers? NO__ YES__ Name & address: __________________________

Describe collateral, if any (eg. car, household goods pledged for loan, or house):

Most recent Collection agency/attorney:

Address: City: ST ZIP -

Creditor____________________________________Address:

City: ST ZIP - Account number:

Balance: $________Check one: Loan ___ credit purchases ____ cash advance ____ medical____ utility ____ other___

Date opened: _____ last used _____Approx. date range bulk of debt incurred: (Please enter your best guess)

If married, please check: H__, W__, J__; Any co-signers? NO__ YES__ Name & address: __________________________

Describe collateral, if any (eg. car, household goods pledged for loan, or house):

Most recent Collection agency/attorney:

Address: City: ST ZIP -

Creditor____________________________________Address:

City: ST ZIP - Account number:

Balance: $________Check one: Loan ___ credit purchases ____ cash advance ____ medical____ utility ____ other___

Date opened: _____ last used _____Approx. date range bulk of debt incurred: (Please enter your best guess)

If married, please check: H__, W__, J__; Any co-signers? NO__ YES__ Name & address: __________________________

Describe collateral, if any (eg. car, household goods pledged for loan, or house):

Most recent Collection agency/attorney:

Address: City: ST ZIP -

Creditor____________________________________Address:

City: ST ZIP - Account number:

Balance: $________Check one: Loan ___ credit purchases ____ cash advance ____ medical____ utility ____ other___

Date opened: _____ last used _____Approx. date range bulk of debt incurred: (Please enter your best guess)

If married, please check: H__, W__, J__; Any co-signers? NO__ YES__ Name & address: __________________________

Describe collateral, if any (eg. car, household goods pledged for loan, or house):

Most recent Collection agency/attorney:

Address: City: ST ZIP -

Creditor____________________________________Address:

City: ST ZIP - Account number:

Balance: $________Check one: Loan ___ credit purchases ____ cash advance ____ medical____ utility ____ other___

Date opened: _____ last used _____Approx. date range bulk of debt incurred: (Please enter your best guess)

If married, please check: H__, W__, J__; Any co-signers? NO__ YES__ Name & address: __________________________

Describe collateral, if any (eg. car, household goods pledged for loan, or house):

Most recent Collection agency/attorney:

Address: City: ST ZIP -

Creditor____________________________________Address:

City: ST ZIP - Account number:

Balance: $________Check one: Loan ___ credit purchases ____ cash advance ____ medical____ utility ____ other___

Date opened: _____ last used _____Approx. date range bulk of debt incurred: (Please enter your best guess)

If married, please check: H__, W__, J__; Any co-signers? NO__ YES__ Name & address: __________________________

Describe collateral, if any (eg. car, household goods pledged for loan, or house):

Most recent Collection agency/attorney:

Address: City: ST ZIP -

Creditor____________________________________Address:

City: ST ZIP - Account number:

Balance: $________Check one: Loan ___ credit purchases ____ cash advance ____ medical____ utility ____ other___

Date opened: _____ last used _____Approx. date range bulk of debt incurred: (Please enter your best guess)

If married, please check: H__, W__, J__; Any co-signers? NO__ YES__ Name & address: __________________________

Describe collateral, if any (eg. car, household goods pledged for loan, or house):

Most recent Collection agency/attorney:

Address: City: ST ZIP -

Creditor____________________________________Address:

City: ST ZIP - Account number:

Balance: $________Check one: Loan ___ credit purchases ____ cash advance ____ medical____ utility ____ other___

Date opened: _____ last used _____Approx. date range bulk of debt incurred: (Please enter your best guess)

If married, please check: H__, W__, J__; Any co-signers? NO__ YES__ Name & address: __________________________

Describe collateral, if any (eg. car, household goods pledged for loan, or house):

Most recent Collection agency/attorney:

Address: City: ST ZIP -

Creditor____________________________________Address:

City: ST ZIP - Account number:

Balance: $________Check one: Loan ___ credit purchases ____ cash advance ____ medical____ utility ____ other___

Date opened: _____ last used _____Approx. date range bulk of debt incurred: (Please enter your best guess)

If married, please check: H__, W__, J__; Any co-signers? NO__ YES__ Name & address: __________________________

Describe collateral, if any (eg. car, household goods pledged for loan, or house):

Most recent Collection agency/attorney:

Address: City: ST ZIP -

Creditor____________________________________Address:

City: ST ZIP - Account number:

Balance: $________Check one: Loan ___ credit purchases ____ cash advance ____ medical____ utility ____ other___

Date opened: _____ last used _____Approx. date range bulk of debt incurred: (Please enter your best guess)

If married, please check: H__, W__, J__; Any co-signers? NO__ YES__ Name & address: __________________________

Describe collateral, if any (eg. car, household goods pledged for loan, or house):

Most recent Collection agency/attorney:

Address: City: ST ZIP -

Creditor____________________________________Address:

City: ST ZIP - Account number:

Balance: $________Check one: Loan ___ credit purchases ____ cash advance ____ medical____ utility ____ other___

Date opened: _____ last used _____Approx. date range bulk of debt incurred: (Please enter your best guess)

If married, please check: H__, W__, J__; Any co-signers? NO__ YES__ Name & address: __________________________

Describe collateral, if any (eg. car, household goods pledged for loan, or house):

Most recent Collection agency/attorney:

Address: City: ST ZIP -

Creditor____________________________________Address:

City: ST ZIP - Account number:

Balance: $________Check one: Loan ___ credit purchases ____ cash advance ____ medical____ utility ____ other___

Date opened: _____ last used _____Approx. date range bulk of debt incurred: (Please enter your best guess)

If married, please check: H__, W__, J__; Any co-signers? NO__ YES__ Name & address: __________________________

Describe collateral, if any (eg. car, household goods pledged for loan, or house):

Most recent Collection agency/attorney:

Address: City: ST ZIP -

Creditor____________________________________Address:

City: ST ZIP - Account number:

Balance: $________Check one: Loan ___ credit purchases ____ cash advance ____ medical____ utility ____ other___

Date opened: _____ last used _____Approx. date range bulk of debt incurred: (Please enter your best guess)

If married, please check: H__, W__, J__; Any co-signers? NO__ YES__ Name & address: __________________________

Describe collateral, if any (eg. car, household goods pledged for loan, or house):

Most recent Collection agency/attorney:

Address: City: ST ZIP -

Creditor____________________________________Address:

City: ST ZIP - Account number:

Balance: $________Check one: Loan ___ credit purchases ____ cash advance ____ medical____ utility ____ other___

Date opened: _____ last used _____Approx. date range bulk of debt incurred: (Please enter your best guess)

If married, please check: H__, W__, J__; Any co-signers? NO__ YES__ Name & address: __________________________

Describe collateral, if any (eg. car, household goods pledged for loan, or house):

Most recent Collection agency/attorney:

Address: City: ST ZIP -

Creditor____________________________________Address:

City: ST ZIP - Account number:

Balance: $________Check one: Loan ___ credit purchases ____ cash advance ____ medical____ utility ____ other___

Date opened: _____ last used _____Approx. date range bulk of debt incurred: (Please enter your best guess)

If married, please check: H__, W__, J__; Any co-signers? NO__ YES__ Name & address: __________________________

Describe collateral, if any (eg. car, household goods pledged for loan, or house):

Most recent Collection agency/attorney:

Address: City: ST ZIP -

Creditor____________________________________Address:

City: ST ZIP - Account number:

Balance: $________Check one: Loan ___ credit purchases ____ cash advance ____ medical____ utility ____ other___

Date opened: _____ last used _____Approx. date range bulk of debt incurred: (Please enter your best guess)

If married, please check: H__, W__, J__; Any co-signers? NO__ YES__ Name & address: __________________________

Describe collateral, if any (eg. car, household goods pledged for loan, or house):

Most recent Collection agency/attorney:

Address: City: ST ZIP -

Creditor____________________________________Address:

City: ST ZIP - Account number:

Balance: $________Check one: Loan ___ credit purchases ____ cash advance ____ medical____ utility ____ other___

Date opened: _____ last used _____Approx. date range bulk of debt incurred: (Please enter your best guess)

If married, please check: H__, W__, J__; Any co-signers? NO__ YES__ Name & address: __________________________

Describe collateral, if any (eg. car, household goods pledged for loan, or house):

Most recent Collection agency/attorney:

Address: City: ST ZIP -

Creditor____________________________________Address:

City: ST ZIP - Account number:

Balance: $________Check one: Loan ___ credit purchases ____ cash advance ____ medical____ utility ____ other___

Date opened: _____ last used _____Approx. date range bulk of debt incurred: (Please enter your best guess)

If married, please check: H__, W__, J__; Any co-signers? NO__ YES__ Name & address: __________________________

Describe collateral, if any (eg. car, household goods pledged for loan, or house):

Most recent Collection agency/attorney:

Address: City: ST ZIP -

Creditor____________________________________Address:

City: ST ZIP - Account number:

Balance: $________Check one: Loan ___ credit purchases ____ cash advance ____ medical____ utility ____ other___

Date opened: _____ last used _____Approx. date range bulk of debt incurred: (Please enter your best guess)

If married, please check: H__, W__, J__; Any co-signers? NO__ YES__ Name & address: __________________________

Describe collateral, if any (eg. car, household goods pledged for loan, or house):

Most recent Collection agency/attorney:

Address: City: ST ZIP -

Creditor____________________________________Address:

City: ST ZIP - Account number:

Balance: $________Check one: Loan ___ credit purchases ____ cash advance ____ medical____ utility ____ other___

Date opened: _____ last used _____Approx. date range bulk of debt incurred: (Please enter your best guess)

If married, please check: H__, W__, J__; Any co-signers? NO__ YES__ Name & address: __________________________

Describe collateral, if any (eg. car, household goods pledged for loan, or house):

Most recent Collection agency/attorney:

Address: City: ST ZIP -

Creditor____________________________________Address:

City: ST ZIP - Account number:

Balance: $________Check one: Loan ___ credit purchases ____ cash advance ____ medical____ utility ____ other___

Date opened: _____ last used _____Approx. date range bulk of debt incurred: (Please enter your best guess)

If married, please check: H__, W__, J__; Any co-signers? NO__ YES__ Name & address: __________________________

Describe collateral, if any (eg. car, household goods pledged for loan, or house):

Most recent Collection agency/attorney:

Address: City: ST ZIP -

Creditor____________________________________Address:

City: ST ZIP - Account number:

Balance: $________Check one: Loan ___ credit purchases ____ cash advance ____ medical____ utility ____ other___

Date opened: _____ last used _____Approx. date range bulk of debt incurred: (Please enter your best guess)

If married, please check: H__, W__, J__; Any co-signers? NO__ YES__ Name & address: __________________________

Describe collateral, if any (eg. car, household goods pledged for loan, or house):

Most recent Collection agency/attorney:

Address: City: ST ZIP -

Creditor____________________________________Address:

City: ST ZIP - Account number:

Balance: $________Check one: Loan ___ credit purchases ____ cash advance ____ medical____ utility ____ other___

Date opened: _____ last used _____Approx. date range bulk of debt incurred: (Please enter your best guess)

If married, please check: H__, W__, J__; Any co-signers? NO__ YES__ Name & address: __________________________

Describe collateral, if any (eg. car, household goods pledged for loan, or house):

Most recent Collection agency/attorney:

Address: City: ST ZIP -

Creditor____________________________________Address:

City: ST ZIP - Account number:

Balance: $________Check one: Loan ___ credit purchases ____ cash advance ____ medical____ utility ____ other___

Date opened: _____ last used _____Approx. date range bulk of debt incurred: (Please enter your best guess)

If married, please check: H__, W__, J__; Any co-signers? NO__ YES__ Name & address: __________________________

Describe collateral, if any (eg. car, household goods pledged for loan, or house):

Most recent Collection agency/attorney:

Address: City: ST ZIP -

Creditor____________________________________Address:

City: ST ZIP - Account number:

Balance: $________Check one: Loan ___ credit purchases ____ cash advance ____ medical____ utility ____ other___

Date opened: _____ last used _____Approx. date range bulk of debt incurred: (Please enter your best guess)

If married, please check: H__, W__, J__; Any co-signers? NO__ YES__ Name & address: __________________________

Describe collateral, if any (eg. car, household goods pledged for loan, or house):

Most recent Collection agency/attorney:

Address: City: ST ZIP -

Creditor____________________________________Address:

City: ST ZIP - Account number:

Balance: $________Check one: Loan ___ credit purchases ____ cash advance ____ medical____ utility ____ other___

Date opened: _____ last used _____Approx. date range bulk of debt incurred: (Please enter your best guess)

If married, please check: H__, W__, J__; Any co-signers? NO__ YES__ Name & address: __________________________

Describe collateral, if any (eg. car, household goods pledged for loan, or house):

Most recent Collection agency/attorney:

Address: City: ST ZIP -

Creditor____________________________________Address:

City: ST ZIP - Account number:

Balance: $________Check one: Loan ___ credit purchases ____ cash advance ____ medical____ utility ____ other___

Date opened: _____ last used _____Approx. date range bulk of debt incurred: (Please enter your best guess)

If married, please check: H__, W__, J__; Any co-signers? NO__ YES__ Name & address: __________________________

Describe collateral, if any (eg. car, household goods pledged for loan, or house):

Most recent Collection agency/attorney:

Address: City: ST ZIP -

Creditor____________________________________Address:

City: ST ZIP - Account number:

Balance: $________Check one: Loan ___ credit purchases ____ cash advance ____ medical____ utility ____ other___

Date opened: _____ last used _____Approx. date range bulk of debt incurred: (Please enter your best guess)

If married, please check: H__, W__, J__; Any co-signers? NO__ YES__ Name & address: __________________________

Describe collateral, if any (eg. car, household goods pledged for loan, or house):

Most recent Collection agency/attorney:

Address: City: ST ZIP -

Creditor____________________________________Address:

City: ST ZIP - Account number:

Balance: $________Check one: Loan ___ credit purchases ____ cash advance ____ medical____ utility ____ other___

Date opened: _____ last used _____Approx. date range bulk of debt incurred: (Please enter your best guess)

If married, please check: H__, W__, J__; Any co-signers? NO__ YES__ Name & address: __________________________

Describe collateral, if any (eg. car, household goods pledged for loan, or house):

Most recent Collection agency/attorney:

Address: City: ST ZIP -

Creditor____________________________________Address:

City: ST ZIP - Account number:

Balance: $________Check one: Loan ___ credit purchases ____ cash advance ____ medical____ utility ____ other___

Date opened: _____ last used _____Approx. date range bulk of debt incurred: (Please enter your best guess)

If married, please check: H__, W__, J__; Any co-signers? NO__ YES__ Name & address: __________________________

Describe collateral, if any (eg. car, household goods pledged for loan, or house):

Most recent Collection agency/attorney:

Address: City: ST ZIP -

Creditor____________________________________Address:

City: ST ZIP - Account number:

Balance: $________Check one: Loan ___ credit purchases ____ cash advance ____ medical____ utility ____ other___

Date opened: _____ last used _____Approx. date range bulk of debt incurred: (Please enter your best guess)

If married, please check: H__, W__, J__; Any co-signers? NO__ YES__ Name & address: __________________________

Describe collateral, if any (eg. car, household goods pledged for loan, or house):

Most recent Collection agency/attorney:

Address: City: ST ZIP -

Creditor____________________________________Address:

City: ST ZIP - Account number:

Balance: $________Check one: Loan ___ credit purchases ____ cash advance ____ medical____ utility ____ other___

Date opened: _____ last used _____Approx. date range bulk of debt incurred: (Please enter your best guess)

If married, please check: H__, W__, J__; Any co-signers? NO__ YES__ Name & address: __________________________

Describe collateral, if any (eg. car, household goods pledged for loan, or house):

Most recent Collection agency/attorney:

Address: City: ST ZIP -

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