Post on 14-Aug-2020
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Doan Law Firm, LLP Phone: (760) 746-4476 Shawn A Doan Fax: (760) 746-4436 320 E 2nd Ave Ste 108 Email: shawn@doanlaw.com Escondido, CA 92025
BANKRUPTCY WORKSHEETS
PLEASE RETURN BY:
Part A. Name and Address
Name: Last First Middle Telephone Numbers Home: Work: Mobile: Have you used any other names in the past six years? No Yes (If yes, list other names) Social Security Number: - - Address: City: State: Zip: County: Have you lived at this address for at least 180 days? No Yes If you have a different mailing address, please list: Address: City: State: Zip: Part B. Name and Address of Spouse If you are filing jointly with your spouse, fill in the following information about your spouse:
Name: Last First Middle Telephone Numbers Home: Work: Mobile: Have you used any other names in the past six years? No Yes (If yes, list other names) Social Security Number: - - Address (if different from your address): City: State: Zip: County: Have you lived at this address for at least 180 days? No Yes If you have a different mailing address, please list: Address: City: State: Zip: Part C. Prior/Pending Bankruptcy Cases Has a bankruptcy case been filed by you or against you in the last 6 years? No Yes If yes, in which district of which state was the case filed? Case Number: Date filed: Are there currently any bankruptcy cases pending against you, your business, your spouse, or your spouse’s business? No Yes If yes, name of debtor: Relationship to you: Case Number: Date Filed: Judge: In which district of which state was the case filed?
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PROPERTY Part A. Real Estate (Schedule A) List any and all real estate which you own or are a joint owner of, even if you still owe money on the property.
Address and Description of Property (House/Condo/etc.)
Title property is held under.
Your % of ownership (100%, 50%., etc.)
Current Market Value (Based upon appraisal or recent comps)
List all Mortgages, Home Equity Loans, and Liens: What is the amount you still owe on the loan, lien, or mortgage?
Who issued the lien, loan or mortgage? (Name, Address of Institution) Please supply Mortgage Statement(s) and Trust Deed(s)
Date of Purchase?
Purchase Price? Homestead No?
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Part B. Personal Property (Schedule B) For each type of property listed below, indicate whether you own any property of that category no matter how low of value! You can think of the market value as the resale value, the amount you would expect to receive at a garage sale.
Type of Property
Do you have any worth more than one cent?
Yes/No
Description
Location
Who Owns:
Husband, Wife, Both?
Value
1 Cash on hand (MUST LIST!) No Yes
2 Checking/savings account, certificates of deposit, other bank accounts No Yes
(Name, address and Account No)
3 Security deposits held by utility companies, landlord, or others No Yes
(Name, address and Account No)
4 Household goods, furniture, including audio, video, and computer equipment
No Yes a) Subtotal of All Household Goods: $ b) Any Property Worth more than $450.00? No Yes
5 Books, pictures, art objects, records, compact discs, collectibles
No Yes
6 Clothing (MUST LIST!) No Yes
7 Furs and jewelry No Yes
8 Sports, photographic, hobby equipment, firearms No Yes
9 Interest in insurance policies-specify refund or cancellation value No Yes
(Name, address and Account No) TERM or WHOLE LIFE?
Please list the Amount your able to borrow and the Amount payable on death.
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Type of Property
Do you have any worth more than one cent?
Yes/No
Description
Location
Who Owns:
Husband, Wife, Both?
Value
10 Annuities
No Yes
Variable, Equity-indexed, etc…
11 Interests in pension or profit sharing plans and Educational Retirement Plans
No Yes
(Name, address and Account No)
Please supply benefit statement
12 Stock and interests in incorporated/ unincorporated business No Yes
13 Interests in partnerships/joint ventures
No Yes
14 Bonds
No Yes
15 Accounts receivable
No Yes
16 Alimony/family support to which you are entitled
No Yes
17 Other liquidated debts owed to you, including tax refunds
No Yes
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Type of Property
more than one cent? Do you have any worth
Yes/No
Description
Location
Who Owns:
Husband, Wife, Both?
Value
18 Equitable or future interests or life estates
No Yes
19 Interests in estate of descendent or life insurance plan or trust No Yes
20 Other contingent/ unliquidated claims, including tax refunds, counterclaims
No Yes
21 Patents, copyrights, other intellectual property
No Yes
22 Licenses, franchises
No Yes
23 Automobiles, trucks, trailers, and accessories. LIST EVERY CAR!!!
No Yes
MUST supply registration and payoff statement.
24 Boats, motors, and accessories
No Yes
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Type of Property
more than one cent? Do you have any worth
Yes/No
Description
Location
Who Owns:
Husband, Wife, Both?
Value
25 Aircraft and accessories
No Yes
26 Office equipment, supplies
No Yes
27 Machinery, fixtures etc. for business
No Yes
28 Inventory
No Yes
29 Animals
No Yes
30 Crops-growing or harvested No Yes
31 Farming equipment and implements
No Yes
32 Farm supplies, chemicals, feed
No Yes
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Type of Property
more than one cent? Do you have any worth
Yes/No
Description
Location
Who Owns:
Husband, Wife, Both?
Value
33 Other personal property of any kind not listed.(Lawsuits you have filed, insurance claims, divorce settlements)
No Yes
Schedule E Information: PRIORITY UNSECURED DEBTS 1
Do you or your spouse owe any debts to employees for wages, salaries, or commissions, including vacation, severance, or sick leave pay? No Yes If so, identify below the employees and list the persons liable for each debt, the amount owed to each employee and the dates that the wages, etc. were earned.
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Do you or your spouse owe any debts for unpaid employer’s contributions to employee benefit plans? No Yes If so, identify below, the employees, the plan, and the person liable for each debt, and list the amount owed and the dates that the services were rendered that gave rise to the debt.
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Do you or your spouse operate a grain storage facility or a fish produce store or processing facility? No Yes
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Do you or your spouse own any debts for the return of deposits made for the purchase, lease, or rental of property or services that were not provided? No Yes If so, identify below each debt and list the amount owed and the persons liable for each debt.
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Do you or your spouse owe any debts for accrued alimony, maintenance or child support? No Yes If so, identify below who owes it, to whom it is owed, the amount that is owed, and to whom, if anyone the claim has been assigned. Attach a copy of the document that created the obligation.(ATTACH A COPY OF THE COURT ORDER)
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Do you or your spouse owe any debts for local, state, or federal taxes, customs, duties, or penalties? No Yes If so, for each debt identify below the name and address of the entity to whom it is owed, the amount that is owed, and to whom if anyone the claim has been assigned.(ATTACH A COPY OF LAST YEARS TAX RETURN)
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Do you or your spouse have a commitment to the FDIC or another insurer to maintain the capital of federally insured bank or savings and loan institution. No Yes
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CREDITOR INSTRUCTIONS PLEASE READ THESE DIRECTIONS BEFORE FILLING IN CREDITORS!! Creditor Name: Please list the NAME of the Creditor and Name of the Collection Agency in this box if applicable Creditor Address: You must supply an address! Use a Billing or Customer Service address for the Creditor and Collection Agency if applicable. Account No: You must supply an account number. Please make every attempt in ascertaining a number if you do not know one. If it is impossible to obtain a number, please
use your Social Security Number or Last Name. Date: EXTREMELY IMPORTANT! Please supply the approximate time period over which each creditor’s balance was incurred. Typically this would be several years
ago up and until the LAST DATE OF PURCHASE. For example, a credit card debt may have been last used 01/03 and the balance incurred 3 years prior to that. In that situation, the debt would have been incurred from 2000-01/03. Use your best approximation.
Consideration: Please list what the debt was for in general terms.(Credit Card Purchases, Charge Card Purchases, Personal Loan, Bounced Check, Medical Bills, Student Loans, Magazine Subscriptions, etc.)
Balance: Please supply the approximate balance currently outstanding. You do not need to call the creditor unless you can not approximate within 5%.(If balance is $5,000 and you guess $4,500, please call to obtain the correct balance. A good faith approximation of $4,750 would be okay in this example though.)
IT IS IMPOSSIBLE TO FILE YOUR CASE IF ANY OF THE BOXES ARE BLANK. ACCORDINGLY, WE WILL NOT PROCESS YOUR FORMS AND RETURN THEM TO YOU FOR COMPLETION UNTIL FULLY FILLED OUT!
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SECURED CREDITORS - REAL ESTATE (Homes, Condos, Townhomes, Mobile Homes, CoOps, Etc.)
Creditor Name Address Account Number Purchase Date Purchase Price Consideration Current
Balance
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SECURED CREDITORS - PERSONAL PROPERTY (Automobiles, Cycles, ATVs, Jewelry, Furniture, Appliances, Computers, Etc.)
Creditor Name Address Account Number
Purchase Date Purchase Price
Garage Sale Value
Consideration Current Balance
EXAMPLE: Ford Motor Company PO Box 33325, San Diego, CA 92110 555-555555 1/1/1999, $23,000,
now worth $14,000 Automobile $19,462
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UNSECURED CREDITORS (Visa, MasterCard, Medical Bills, Bounced Checks, Collections, Etc.) *LIST ANY COLLECTION AGENCY DIRECTLY AFTER CREDITOR*
Creditor Name Address Account Number
Purchase Date Purchase Price
Garage Sale Value
Consideration Current Balance
Example: SEARS PO Box 5000 Rancho Cucamonga, CA 43216 02-05671984 2/99 - 4/02 Chard Card Purchases $2,612
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UNSECURED CREDITORS (cont’d) (Visa, MasterCard, Medical Bills, Bounced Checks, Collections, Etc.) *LIST ANY COLLECTION AGENCY DIRECTLY AFTER CREDITOR*
Creditor Name Address Account Number
Purchase Date Purchase Price
Garage Sale Value
Consideration Current Balance
Example: SEARS PO Box 5000 Rancho Cucamonga, CA 43216 02-05671984 2/99 - 4/02 Chard Card Purchases $2,612
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UNSECURED CREDITORS (cont’d) (Visa, MasterCard, Medical Bills, Bounced Checks, Collections, Etc.) *LIST ANY COLLECTION AGENCY DIRECTLY AFTER CREDITOR*
Creditor Name Address Account Number
Purchase Date Purchase Price
Garage Sale Value
Consideration Current Balance
Example: SEARS PO Box 5000 Rancho Cucamonga, CA 43216 02-05671984 2/99 - 4/02 Chard Card Purchases $2,612
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UNSECURED CREDITORS (cont’d) (Visa, MasterCard, Medical Bills, Bounced Checks, Collections, Etc.) *LIST ANY COLLECTION AGENCY DIRECTLY AFTER CREDITOR*
Creditor Name Address Account Number
Purchase Date Purchase Price
Garage Sale Value
Consideration Current Balance
Example: SEARS PO Box 5000 Rancho Cucamonga, CA 43216 02-05671984 2/99 - 4/02 Chard Card Purchases $2,612
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CURRENT INCOME Marital Status List all dependents of you and your spouse, their ages, and their relationship to you Married Name Age Relationship
Single
Divorced
Separated
Widowed
Part A. Debtor’s Income Part B. Joint Debtor’s Income
1. What is your occupation? 1. What is your spouse’s occupation? 2. Name and Address of your employer: 2. Name and Address of your employer:
3. How long have you been employed there? 3. How long have you been employed there? 4. What is the gross amount of your paycheck, before taxes, 4. What is the gross amount of your spouse’s paycheck, before taxes, other deductions are taken out? $ other deductions are taken out? $ 5. How often do you get paid? Once a week 5. How often do you get paid? Once a week every two weeks twice a month every two weeks twice a month once a month other once a month other6. Do you receive overtime pay outside of your salary? 6. Does your spouse receive overtime pay outside of your salary? No Yes No Yes If so, how much per month? $ If so, how much per month? $ 7. How much is taken out of each paycheck for taxes and social 7. How much is taken out of each paycheck for taxes and social security? $ security? $ 8. How much is taken out for insurance? $ 8. How much is taken out for insurance? $ 9. How much for Union dues? $ 9. How much for Union dues? $ 10. Are there other deductions? No Yes 10.Are there other deductions? No Yes If So, what are they and how much? If So, what are they and how much? Do you receive… Does your spouse receive… a) income from business operations outside of your regular a) income from business operations outside of your regular paycheck listed above? No Yes paycheck listed above? No Yes If so, what is the business and how much do you receive If so, what is the business and how much does your spouse per month? receive per month? b) Income from real estate property? No Yes b) Income from real estate property? No Yes If so, how much per month? $ If so, how much per month? $ c) Interest or dividends? No Yes c) Interest or dividends? No Yes If so, how much per month? $ If so, how much per month? $ d) alimony or family support payments for your use or for the d) alimony or family support payments for your use or for the care of your dependents? No Yes care of your dependents? No Yes If so, how much per month? $ If so, how much per month? $ e) social security or other forms of monetary government e) social security or other forms of monetary government assistance? No Yes assistance? No Yes If so, how much per month? $ If so, how much per month? $ f) retirement or pension money? No Yes f) retirement or pension money? No Yes If so, how much per month? $ If so, how much per month? $ Do you have any other sources of income not listed? Does your spouse have any other sources of income not listed? No Yes No Yes
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Are you or your spouse expecting any increase or decrease in salary of more than 10% in the next year? No Yes If so, explain:
CURRENT EXPENSES
Do you and your spouse maintain separate households? No Yes. If so, split the column in half and list each of your separate expenses. 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 amount. Indicate how much you pay for each item each month . . . 1. Your rent or your home mortgage $ Does that amount include real estate taxes? No Yes Does it include property insurance? No Yes 2. Electricity and heating $ 3. Water and sewage $ 4. Telephone service/long distance $ 5. Do you have any other utility bills? No Yes If so, what and how much per month? $ 6. Home maintenance, including repairs and general upkeep $ 7. Food $ 8. Clothing $ 9. Laundry and dry cleaning $ 10. Medical and dental expenses $ 11. Transportation (not including car payments) $ 12. Entertainment, recreation, newspapers, magazines $ 13. Charitable contributions $ 14. Insurance not deducted from paycheck $ a) homeowner’s or renter’s insurance $ b) life insurance $ c) health insurance $ d) auto insurance $ e) other insurance $ 15. Taxes not deducted from paycheck $ 16. Installment payments for car, furniture, etc. (Specify) $ 17. Alimony, maintenance, support paid to others $ 18. Payments for support of dependents not living at home $ 19 Expenses from operation of business $ 20. Other expenses not listed above (pets, storage, bank fees, etc) $ FINANCIAL AFFAIRS 1. How much did you earn in 2006: $ How much did you earn in 2007: $ How much have you earned this year so far: $ How much did your spouse earn in 2006: $ How much did your spouse earn in 2007: $ How much has your spouse earned this year so far: $
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2. Please describe income other than employment (social security, state disability, unemployment, workers compensation, rental income, garage sale income, etc…)
2006 Your Source of Income: Amount: $ 2007 Your Source of Income: Amount: $ Year to Date Source of Income: Amount: $ 2006 Spouse Source of Income: Amount: $ 2007 Spouse Source of Income: Amount: $ Year to Date Spouse Source of Income: Amount: $ Please Carefully Read And Answer Yes Or No To Each Of The Following Questions: 3. a) Have you cumulatively paid over $600 to any creditor in the past 3 months? No Yes (example: $205/month car payment @ 3 months = $615) b) Have you cumulatively paid over $600 to any creditor who is a relative or business No Yes associate within the past 2 years? 4. a) Has anyone sued you or have you sued anyone in the last 12 months? No Yes (Please provide caption, case no, court address, and current status below) b) Has any property been seized or garnished in the last 12 months? No Yes (Please describe property, date, and name and address who took) 5. 5. Have you had any repossessions or foreclosures in the past 12 months? No Yes 6. a) Has any of your property been assigned to a trustee or other third party for the No Yes benefit of creditors within the past 4 months? b) Has any of your property been in the hands of a custodian, receiver, or court- No Yes appointed official within the past 12 months? 7. Have you made any gifts over $200 or charitable contributions over $100 in the past No Yes 12 months? 8. Have you had any losses from gambling, fire, theft, or other casualty within the past No Yes 12 months? 9. Have you made payments relating to debt consolidation or paid any other attorneys No Yes or paralegals(excluding us) for bankruptcy petition preparation within the past 12 months? 10. Have you made any other transfers of property over $500.00 in the past 12 months? No Yes 11. Have you closed any bank or similar financial accounts such as credit union No Yes accounts within the past 12 months? 12. Have you had a safe deposit box in the past 12 months? No Yes 13. Has a bank or other financial institution, or any other creditor, setoff a debt against No Yes your bank account or other funds owing you within the past 3 months? 14. Are you holding any property or bank accounts in your name that actually belongs No Yes to someone else? (Such as a child’s savings account) 15. Have you lived anywhere else other than your current address in the past 3 years? No Yes (Please provide complete address, name used, and dates below)
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16. Please list the name(s) of all spouses and/or former spouses in the past 6 years:
For each YES answer above(except 4 and 15), please provide the following: NAME, ADDRESS, DATE, and AMOUNT! If you indicated YES to #4 Under personal property please itemize. It is impossible to process your petition without this information.
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