Bankruptcy Worksheet - Law Offices of Steven A. Wolvek

First Name:
Middle Name:
Last Name:
Street Address:
City:
State:
Zip:
Home Phone:
Cell Phone:
Email Address:
Other Names:	Other names you have used in the last (6) years?
Marital Status:

PRIOR BANKRUPTCIES:
If you have previously filed a bankruptcy petition, please fill out the fields below:

Description:
Case Number:
Date:
Outcome:
Location:

Yes No	POTENTIAL INHERITANCE: Are you the beneficiary of a will where you will inherit property in the near future?
Yes No	TRANSFERS: Have you sold, transferred or given away any property that you owned outright or that you were paying for on time in the last year?
Yes No	LOAN APPLICATIONS: Have you ever given a false financial statement to obtain a loan?
Yes No	LAW SUITS: Do you have the right to file a personal injury case, workers compensation or other law suit against anyone?
Yes No	Have you lived in this jurisdiction the last 90 days?
Yes No	Have you paid any debts to any relatives in the last year?
Yes No	Do you have any debts resulting from a D.U.I.?
Yes No	Do you have any debts resulting from a Criminal Fine?
Yes No	Do you have any debts resulting from Student Loans or Tuition?
Yes No	Do you owe any taxes?
Yes No	Have you taken credit card cash advances to pay taxes?
Yes No	Are you on title to anyone else's property?
Yes No	Have you co-signed for another's debt?
Yes No	Has anyone co-signed for any of your obligations?
Yes No	Have you ever had a HUD, VA or Cal Vet loan?

REAL PROPERTY:
Is land and things permanently attached to land including unimproved land, vacation cabins, condominiums, duplexes, rental properties, business properties, mobile home park spaces, agricultural land, airplane hangers, and other buildings permanently attached to land. Also include property you are entitled to by a trust and all property in which you have any legal, equitable, or future interest, include property owned by either spouse.


Address: (include City and Zip)
Market Value:
Amount Owed:


1st Trust Deed Holder:
Monthly Mortgage Payment:
Due Date:
Number of Payments Behind:


2nd Trust Deed Holder:
Monthly Mortgage Payment:
Due Date:
Number of Payments Behind:

Yes No

Do you own any other real property, raw land or timeshares?

PERSONAL PROPERTY:
List all property you own. If you do not own property in a specific category, please place an 'X' in the description column. When the value of the property is requested, please use a liquidation or yard sale value.

Property Description	Value
1. Cash on Hand
2. Bank Accounts Credit Union Accts
3. Security Deposits
4. Household Goods
5. Books, Art and Collectibles
6. Wearing Apparel
7. Furs and Jewelry
8. Guns, Hobby and Sports Equipment
9. Interests in Insurance Accounts
10. Annuities
11. IRA, KEOGH or Pension Plans
12. Stocks or Business Interests
13. Interests in Partnerships/Joint Ventures
14. Govt & Corporate Bonds/Notes
15. Accounts Receivables
16. Alimony, Support, Maintenance and Property Settlements
17. Other Liquidated Debts/Tax Refunds
18. Equitable or Future Interests/Life Estates
19. Contingent/Non-Contingent Interests in a Will
20. Other Contingent/Unliquidated Debts
21. Patents, Copyrights/Intellectual Property
22. Licenses/Franchises
23. Automobiles, Trucks, Trailers and other Vehicles
24. Boats, Motors & Accessories
25. Aircraft & Accessories
26. Office Equipment, Furniture & Supplies
27. Machinery, Fixtures, Equipment & Supplies used in Business
28. Inventory
29. Animals
30. Crops Growing or Harvested
31. Farming Equipment & Implements
32. Farm Supplies, Chemicals & Feed
33. All other Property not listed
34. Household Goods & Furniture

LEASES OR CONTRACTS:
Are you a party to any leases or contracts? If yes, list the parties involved and their addresses:

INCOME AND EXPENSE

YOUR EMPLOYMENT INFORMATION:
Occupation:
Length of Employment:
Employer's Name:
Employer's Address:
SPOUSE'S EMPLOYMENT INFORMATION:
Occupation:
Length of Employment:
Employer's Name:
Employer's Address:
DEPENDENTS:
Name & Age:

MONTHLY INCOME

	DEBTOR (YOU)	SPOUSE
Monthly Gross Wages, Salary, Commissions
Estimated Monthly Overtime
Subtract Payroll Taxes and Social Security
Subtract Insurance
Subtract Union Dues
Other Payroll Deductions-Specify
Regular Monthly Income from Business or Profession
Monthly Income from Real Property
Monthly Interest and Dividends
Alimony, Maintenance or Support Payments (For your or your dependents use)
Social Security or Government Assistance
Pension or Retirement
NAME:

MONTHLY EXPENSES

	Debtor(s)
Rent/Mortgage (Add property tax if paid separately)
Electricity and Heating
Water and Sewer
Telephone
Other Utilities
Home Maintenance/Repairs
Food
Clothing
Laundry and Dry Cleaning
Medical and Dental Expenses
Transportation (not including car payments)
Recreation, Clubs and Entertainment
Charitable Contributions
Homeowners/Renters Insurance
Life Insurance
Health Insurance
Auto Insurance
Other Insurance - Specify
Taxes (not deducted from wages or in home mortgage payments)
Installment Auto Payments
Other Installment Payments
Alimony, Maintenance and Support paid to Others
Payments for Dependents not Living at Home
Operation Expenses of Business, Profession or Farm
Total Credit Card Debt

PLEASE ANSWER THE FOLLOWING QUESTIONS: DO NOT LEAVE ANY QUESTION BLANK. IF THE QUESTION IS NOT APPLICABLE TO YOUR SITUATION - WRITE "N/A"

1. List amount of income from employment, or operation of business, for each of the last two years:

Amount:
Source:
Fiscal Period:

2. Income other than from employment or operation of business for the last two years:

Amount:
Source:
Fiscal Period:

3. A. List all payments to creditors, within the last 90 days, totaling $600.00 or more:
Name and Address of Creditor / Amount paid and Amount still owed

B. List all payments made within the last year to creditors who were family members:

4. A. List all lawsuits or garnishments you are involved in as a plaintiff or defendant:
Caption of Suit/Case Number Action Court Location Status

B. List all property attached or seized within last year:
Name and Address of Creditor Date of Seizure Value of Property

5. List all completed Repossessions, Foreclosures and Returns:
Name and Address of Creditor Date Description of Property

6. List all properties assigned, or placed in the hands of a receiver, within the last year:
Name and Address of Assignee Date of Assignment Terms

7. List all large gifts made within the last year:
Name of Person Relation Description of Gift

8. List all losses from theft, fire, or gambling within the last year:
Description and Value of Property Date of Loss

9. List all payments to attorneys or others regarding bankruptcy within the last year:
Name of Payee Date of Payment Amount

10. List all valuable properties sold, transferred, given away, or put into someone else's hands, within the last 12 months:
Name of Transferee/Relation Describe Property Value

11. List all closed financial accounts:
Name and Address of Institution Type of Account Amount/Date

12. List all safe deposit boxes held within the last year:
Name and Address of Bank Description of Contents

13. List all creditors to whom property was given in exchange for forgiving a debt:
Name and Address of Creditor Date Amount of Set-off

14. List all your properties held by another:
Holder's Name Description of Property Location of Property

15. If you have moved within the last two years, list all past addresses:
Address Date of Occupancy

PLEASE COMPLETE QUESTIONS 16 - 21 IF YOU WERE MEMBER OF A CORPORATION OR PARTNERSHIP WITHIN THE LAST 2 YEARS

16. List the Name, Location and Nature of the Business:

17. List all bookkeepers and accountants who, within the last 6 years, have kept business records: Name and Address Date Services were Rendered

18. List the dates of last 2 inventories taken and the dollar amount of each inventory:
Date of Inventory Name of Person Taking Inventory Value

19. If in a current partnership, list the nature and percentage of interest in the partnership:

20. List all former partners who withdrew from the partnership within the last year:

21. List all withdrawals by or distributions to insiders within the last year:

Your Privacy and Confidentiality is Protected.

We do not disclose, sell, trade, rent, lease or otherwise
transfer your personal information to outside parties.

Please read, fill out and sign form, and fax or email back to us.
Email Authorization Form

The Law Offices of Steven A. Wolvek

Helping Families get a Fresh Financial Start

Bankruptcy Questionnaire Worksheet