Debtor:
Last:
First:
Middle:
List All Other Names used in the last eight (8) Years:
Social Security Number: (used only for the purpose of the petition)
Home Phone:
Cell Phone:
Work Phone:
Street Address:
Unit # (if any)
City:
State:
Zip Code:
County of Residence:
Debtor's Mailing Address if different from street Address:
Joint Debtor:
Last:
First:
Middle:
List All Other Names used in the last eight (8) Years:
Social Security Number: (used only for the purpose of the petition)
Home Phone:
Cell Phone:
Work Phone:
Street Address:
Unit # (if any)
City:
State:
Zip Code:
County of Residence:
Debtor's Mailing Address if different from street Address:
Prior Bankruptcy Case(s) Filed in Last 8 Years (if any): (If none please state "None')
Full Name of Debtor:
Location Where Filed: (ie. County)
Case Number:
Chapter:
Date Filed:
Full Name of Debtor:
Location Where Filed: (ie. County)
Date Filed:
Chapter:
Case Number:
Pending Bankruptcy Case filed by any Spouse, Partner, or Affiliate of the Debtor:
Name of Debtor:
Relationship:
Case No:
Chapter:
Date Filed:
Judge:
District:
Name of Debtor:
Relationship:
Case No:
Chapter:
Date Filed:
Judge:
District:
Statement of Debtor who resides as a Tenant of Residential Property:
Name of Landlord that obtained judgment:
Address of Landlord:
Estimated/Average Expenses:
Joint Debor/
Spouse
Debtor
1. Rent or home mtg. pmt.
(include lot rent for mobile home)
Are real estate taxes included?
Is property insurance included?
2. Utilities
a. Electricity and heating fuel 2. a.
b. Water and sewer b.
c. Telephone c.
d. Other d.
3. Home maintenance (repairs & upkeep)
4. Food
5. Clothing
6. Laundry & dry cleaning
7. Medical & dental expenses
8. Transportation (not including car payments)
9. Recreation, clubs, entertainment, newspapers etc.
10. Charitable contributions
11. Insurance (not deducted from wages or included in mtg. pmt.)
a. Homeowner's or renter's
b. Life
c. Health
d. Auto
e. Other
12. Taxes (not deducted from wages or included in mtg. pmt.)
Specify:
13. Installment Pmts.
(In chapter 11,12 &13 cases, do not list pmts. to be included in plan)
a. Auto
b. Other
c. Other
d. Other
14. Alimony, maintenance, & support paid to others
15. Pmts. for support of add'l dependents not living with you
16. Reg. expenses from operation of business, profession, farm
17. Other
18. Describe any increase or decrease in expenses reasonably anticipated to occur within the year following the filing.
Bankruptcy Questionnaire
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