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Personal bankruptcy questionnaire

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Write only the last four SSN digits. Never email sensitive information or completed financial questionnaires.

Source page 1 · 0 mapped fields

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L A W O F F I C E S O F
Wendy Turner Lewis, PLLC
Detroit, Michigan  |  313.832.5555  |  
Personal Bankruptcy Questionnaire
C H A P T E R 7   ·   I N D I V I D U A L & J O I N T F I L E R S
United States Bankruptcy Court  ·  Eastern District of Michigan
C O N F I D E N T I A L — A T T O R N E Y – C L I E N T P R I V I L E G E D
www.wendyturnerlewis.com

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Please read this !rst
Thank you for trusting the Law Ofﬁces of Wendy Turner Lewis, PLLC. This
questionnaire gathers what we need to prepare your Chapter 7 petition,
schedules, and Statement of Financial Affairs. Everything you write here
is reproduced in documents you sign under penalty of perjury, so please
be accurate and complete — list all of your assets and all of your
liabilities.
Bankruptcy Information Sheet. Federal law requires us to give every
individual ﬁler the Bankruptcy Information Sheet prepared by the U.S.
Department of Justice, which explains the bankruptcy chapters and your
rights. A copy is included with this packet — please review it and check
the box in Section 6 conﬁrming you received it.
Credit counseling — before ﬁling. You must complete an approved
credit-counseling brieﬁng from a court-approved agency within the 180
days before your case is ﬁled. You will receive a certiﬁcate we must ﬁle
with the court.
Debtor education — after ﬁling. After your case is ﬁled, you must
complete a second approved course — a ﬁnancial management (debtor
education) course — and ﬁle its certiﬁcate before the court will grant
your discharge. Both courses are required.
The 8-year rule. You generally cannot receive a Chapter 7 discharge if you
already received one in a Chapter 7 case ﬁled within the last 8 years
(measured ﬁling date to ﬁling date). Tell us about any prior ﬁling in
Section 5.
Your taxes must be ﬁled. Your required federal and state tax returns
must be ﬁled and current, and you must provide your last 2 years of
returns. The trustee requires your most recently ﬁled return before your
341 meeting.
Answer every item. If something does not apply, write “None” or “N/A” —
do not leave blanks. Attach extra sheets if you need more room.
This form is conﬁdential attorney work product. Completing it helps us serve
you; it does not by itself create representation, which begins only under a
signed engagement agreement with the ﬁrm.

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1
Debtor Information
FULL LEGAL NAME (FIRST, MIDDLE, LAST, SUFFIX)
OTHER NAMES USED IN THE LAST 8 YEARS maiden, former, married, DBA
LAST 4 OF SOCIAL SECURITY NUMBER
DATE OF BIRTH
HOME STREET ADDRESS (CITY, STATE, ZIP, COUNTY)
MAILING ADDRESS (IF DIFFERENT)
HOW LONG AT THIS ADDRESS?
MARITAL STATUS
Enter your exact legal name and every other name you have used in the
last 8 years (maiden, former, married, or business names). For your
protection, list only the last four digits of your Social Security number
here — gather your Social Security card so we can verify the full number
securely.

FULL LEGAL NAME (FIRST, MIDDLE, LAST, SUFFIX) (source page 3, field 1)

OTHER NAMES USED IN THE LAST 8 YEARS maiden, former, married, DBA (source page 3, field 2)

LAST 4 OF SSN — last 4 digits only (source page 3, field 3)

DATE OF BIRTH (source page 3, field 4)

HOME STREET ADDRESS (CITY, STATE, ZIP, COUNTY) (source page 3, field 5)

MAILING ADDRESS (IF DIFFERENT) (source page 3, field 6)

HOW LONG AT THIS ADDRESS? (source page 3, field 7)

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HOME PHONE
CELL PHONE
EMAIL
PRIOR ADDRESSES IN THE LAST 3 YEARS
2
Spouse / Joint Debtor
A married couple may ﬁle jointly in one case. Even if only one spouse
ﬁles, we generally must still account for the other spouse’s income.
Complete this if you are married, whether or not your spouse is ﬁling.
ARE YOU FILING JOINTLY WITH YOUR SPOUSE? Yes / No — spouse not ﬁling / Not
married
SPOUSE FULL LEGAL NAME
SPOUSE OTHER NAMES (LAST 8 YEARS)
SPOUSE LAST 4 OF SSN

HOME PHONE (source page 4, field 1)

CELL PHONE (source page 4, field 2)

EMAIL (source page 4, field 3)

PRIOR ADDRESSES IN THE LAST 3 YEARS (source page 4, field 4)

married (source page 4, field 5)

SPOUSE FULL LEGAL NAME (source page 4, field 6)

SPOUSE OTHER NAMES (LAST 8 YEARS) (source page 4, field 7)

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SPOUSE DATE OF BIRTH
SPOUSE EMPLOYER / OCCUPATION
SPOUSE PHONE / EMAIL
3
Household & Dependents
Your household size affects the means test and your budget. List everyone
who lives in your home and everyone you support ﬁnancially.
NUMBER OF PEOPLE IN YOUR HOUSEHOLD
DO YOU SUPPORT ANYONE OUTSIDE YOUR HOME?
DEPENDENT NAME
RELATIONSHIP
AGE
LIVES WITH
YOU?

DEPENDENT NAME (source page 5, field 1)

RELATIONSHIP (source page 5, field 2)

AGE (source page 5, field 3)

YOU? (source page 5, field 4)

SPOUSE DATE OF BIRTH (source page 5, field 5)

SPOUSE EMPLOYER / OCCUPATION (source page 5, field 6)

SPOUSE PHONE / EMAIL (source page 5, field 7)

NUMBER OF PEOPLE IN YOUR HOUSEHOLD (source page 5, field 8)

DO YOU SUPPORT ANYONE OUTSIDE YOUR HOME? (source page 5, field 9)

DEPENDENT NAME (source page 5, field 10)

RELATIONSHIP (source page 5, field 11)

AGE (source page 5, field 12)

YOU? (source page 5, field 13)

DEPENDENT NAME (source page 5, field 14)

RELATIONSHIP (source page 5, field 15)

AGE (source page 5, field 16)

YOU? (source page 5, field 17)

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4
Self-Employment & Business Interests
If you own or owned a business, are self-employed, or have business
debts you are personally responsible for, tell us here. Otherwise write
“None.”
BUSINESS / DBA NAME
TYPE & YOUR ROLE (OWNER %, OFFICER, MEMBER)
EIN (IF ANY)
STILL OPERATING? IF CLOSED, DATE CLOSED
NATURE OF THE BUSINESS
BUSINESS ASSETS YOU OWN (EQUIPMENT, INVENTORY, RECEIVABLES) — WITH
VALUES

BUSINESS / DBA NAME (source page 6, field 1)

TYPE & YOUR ROLE (OWNER %, OFFICER, MEMBER) (source page 6, field 2)

EIN (IF ANY) (source page 6, field 3)

STILL OPERATING? IF CLOSED, DATE CLOSED (source page 6, field 4)

NATURE OF THE BUSINESS (source page 6, field 5)

VALUES (source page 6, field 6)

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5
Prior Bankruptcy Filings & the 8-Year Rule
List every bankruptcy you (or your spouse) ﬁled in the last 8 years.
Remember: a prior Chapter 7 discharge within 8 years can bar a new
Chapter 7 discharge, so this is important.
Have you or your spouse ﬁled bankruptcy before?
Yes
No
WHO FILED
CHAPTER
CASE
NUMBER
DISTRICT
FILING
DATE
DISCHARGED
/
DISMISSED?
6
Bankruptcy Information Sheet & Required
Courses
Two counseling courses are mandatory — one before ﬁling (credit
counseling) and one after ﬁling (debtor education). We cannot obtain
your discharge until both certiﬁcates are ﬁled. Please also conﬁrm you
received the Bankruptcy Information Sheet.
I have received and reviewed the Bankruptcy Information Sheet provided
with this packet.
Yes, received
PRE-FILING CREDIT COUNSELING — COMPLETED? Yes / No / Scheduled

WHO FILED (source page 7, field 1)

CHAPTER (source page 7, field 2)

NUMBER (source page 7, field 3)

DISTRICT (source page 7, field 4)

DATE (source page 7, field 5)

DISMISSED? (source page 7, field 6)

WHO FILED (source page 7, field 7)

CHAPTER (source page 7, field 8)

NUMBER (source page 7, field 9)

DISTRICT (source page 7, field 10)

DATE (source page 7, field 11)

DISMISSED? (source page 7, field 12)

WHO FILED (source page 7, field 13)

CHAPTER (source page 7, field 14)

NUMBER (source page 7, field 15)

DISTRICT (source page 7, field 16)

DATE (source page 7, field 17)

DISMISSED? (source page 7, field 18)

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PRE FILING CREDIT COUNSELING 
 COMPLETED? Yes / No / Scheduled
DATE COMPLETED
APPROVED AGENCY / PROVIDER NAME
CERTIFICATE NUMBER (IF YOU HAVE IT)
POST-FILING DEBTOR-EDUCATION COURSE — COMPLETED OR PLANNED? we will
remind you; it is required before discharge
7
Means Test — Income for the Last 6
Months
The “means test” looks at your household’s average gross income over
the last 6 full calendar months and compares it to the Michigan median
for your household size. Enter gross (before-tax) amounts from all
sources — job income, self-employment, unemployment, support
received, rental, etc. (Social Security beneﬁts are listed but treated
separately.)
MONTH
YOUR GROSS
INCOME
SPOUSE
GROSS
INCOME
OTHER
HOUSEHOLD
INCOME
SOURCE(S)

PRE FILING CREDIT COUNSELING (source page 8, field 1)

DATE COMPLETED (source page 8, field 2)

APPROVED AGENCY / PROVIDER NAME (source page 8, field 3)

CERTIFICATE NUMBER (IF YOU HAVE IT) (source page 8, field 4)

remind you; it is required before discharge (source page 8, field 5)

MONTH (source page 8, field 6)

INCOME (source page 8, field 7)

INCOME (source page 8, field 8)

INCOME (source page 8, field 9)

SOURCE(S) (source page 8, field 10)

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HOUSEHOLD SIZE FOR THE MEDIAN COMPARISON
ANY INCOME YOU EXPECT TO CHANGE SOON?
8
Current Income & Employment
This is your income as of today, used for Schedule I. Include every current
source for you and your spouse.
PERSON
EMPLOYER /
SOURCE
OCCUPATION
PAY
FREQUENCY
GROSS
MONTHLY
NET
MONTHLY
OTHER INCOME — RENTAL, BUSINESS, SUPPORT, RETIREMENT/SOCIAL

Response 1 (see source page) (source page 9, field 1)

Response 2 (see source page) (source page 9, field 2)

Response 3 (see source page) (source page 9, field 3)

Response 4 (see source page) (source page 9, field 4)

Response 5 (see source page) (source page 9, field 5)

Response 6 (see source page) (source page 9, field 6)

Response 7 (see source page) (source page 9, field 7)

Response 8 (see source page) (source page 9, field 8)

Response 9 (see source page) (source page 9, field 9)

Response 10 (see source page) (source page 9, field 10)

PERSON (source page 9, field 11)

SOURCE (source page 9, field 12)

OCCUPATION (source page 9, field 13)

FREQUENCY (source page 9, field 14)

MONTHLY (source page 9, field 15)

MONTHLY (source page 9, field 16)

Response 17 (see source page) (source page 9, field 17)

Response 18 (see source page) (source page 9, field 18)

Response 19 (see source page) (source page 9, field 19)

Response 20 (see source page) (source page 9, field 20)

Response 21 (see source page) (source page 9, field 21)

Response 22 (see source page) (source page 9, field 22)

Response 23 (see source page) (source page 9, field 23)

Response 24 (see source page) (source page 9, field 24)

Response 25 (see source page) (source page 9, field 25)

Response 26 (see source page) (source page 9, field 26)

Response 27 (see source page) (source page 9, field 27)

Response 28 (see source page) (source page 9, field 28)

Response 29 (see source page) (source page 9, field 29)

Response 30 (see source page) (source page 9, field 30)

Response 31 (see source page) (source page 9, field 31)

Response 32 (see source page) (source page 9, field 32)

Response 33 (see source page) (source page 9, field 33)

Response 34 (see source page) (source page 9, field 34)

Response 35 (see source page) (source page 9, field 35)

Response 36 (see source page) (source page 9, field 36)

HOUSEHOLD SIZE FOR THE MEDIAN COMPARISON (source page 9, field 37)

ANY INCOME YOU EXPECT TO CHANGE SOON? (source page 9, field 38)

PERSON (source page 9, field 39)

SOURCE (source page 9, field 40)

OCCUPATION (source page 9, field 41)

FREQUENCY (source page 9, field 42)

MONTHLY (source page 9, field 43)

MONTHLY (source page 9, field 44)

PERSON (source page 9, field 45)

SOURCE (source page 9, field 46)

OCCUPATION (source page 9, field 47)

FREQUENCY (source page 9, field 48)

MONTHLY (source page 9, field 49)

MONTHLY (source page 9, field 50)

PERSON (source page 9, field 51)

SOURCE (source page 9, field 52)

OCCUPATION (source page 9, field 53)

FREQUENCY (source page 9, field 54)

MONTHLY (source page 9, field 55)

MONTHLY (source page 9, field 56)

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SECURITY, GOVERNMENT BENEFITS
9
Monthly Living Expenses
Your actual monthly expenses, used for Schedule J. Estimate reasonable
averages; we can reﬁne them together.
RENT OR MORTGAGE PAYMENT
REAL ESTATE TAXES (IF NOT IN MORTGAGE)
HOME/RENTER’S INSURANCE (IF NOT IN MORTGAGE)
HOME MAINTENANCE & REPAIRS
ELECTRICITY, HEAT, NATURAL GAS
WATER, SEWER, GARBAGE
PHONE, INTERNET, CABLE, STREAMING

SECURITY, GOVERNMENT BENEFITS (source page 10, field 1)

RENT OR MORTGAGE PAYMENT (source page 10, field 2)

REAL ESTATE TAXES (IF NOT IN MORTGAGE) (source page 10, field 3)

HOME/RENTER’S INSURANCE (IF NOT IN MORTGAGE) (source page 10, field 4)

HOME MAINTENANCE & REPAIRS (source page 10, field 5)

ELECTRICITY, HEAT, NATURAL GAS (source page 10, field 6)

WATER, SEWER, GARBAGE (source page 10, field 7)

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FOOD & HOUSEKEEPING SUPPLIES
CHILDCARE & CHILDREN’S EDUCATION
CLOTHING, LAUNDRY, DRY CLEANING
PERSONAL CARE
MEDICAL & DENTAL (OUT OF POCKET)
TRANSPORTATION (GAS, BUS, MAINTENANCE)
VEHICLE INSURANCE
HEALTH INSURANCE
LIFE INSURANCE
TAXES NOT DEDUCTED FROM PAY
INSTALLMENT / LOAN PAYMENTS (NOT LISTED ELSEWHERE)

FOOD & HOUSEKEEPING SUPPLIES (source page 11, field 1)

CHILDCARE & CHILDREN’S EDUCATION (source page 11, field 2)

CLOTHING, LAUNDRY, DRY CLEANING (source page 11, field 3)

PERSONAL CARE (source page 11, field 4)

MEDICAL & DENTAL (OUT OF POCKET) (source page 11, field 5)

TRANSPORTATION (GAS, BUS, MAINTENANCE) (source page 11, field 6)

VEHICLE INSURANCE (source page 11, field 7)

HEALTH INSURANCE (source page 11, field 8)

LIFE INSURANCE (source page 11, field 9)

TAXES NOT DEDUCTED FROM PAY (source page 11, field 10)

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ALIMONY / CHILD SUPPORT YOU PAY
CHARITABLE CONTRIBUTIONS
OTHER EXPENSES
10
Real Estate You Own
ADDRESS /
DESCRIPTION
MARKET
VALUE
SEV /
TAXABLE
VALUE
OWNER(S)
ON DEED
MORTGAGE
BALANCE &
LENDER
IS ANYONE ELSE ON THE DEED OR A CO-OWNER?
ARE YOU BEHIND ON ANY MORTGAGE OR TAXES?
List every parcel you own or are buying — home, land, rental, timeshare, or
an interest through someone else. For value, use the market value and the
SEV / taxable value from your latest property-tax statement, and gather
the deed.

DESCRIPTION (source page 12, field 1)

VALUE (source page 12, field 2)

VALUE (source page 12, field 3)

ON DEED (source page 12, field 4)

LENDER (source page 12, field 5)

ALIMONY / CHILD SUPPORT YOU PAY (source page 12, field 6)

CHARITABLE CONTRIBUTIONS (source page 12, field 7)

OTHER EXPENSES (source page 12, field 8)

DESCRIPTION (source page 12, field 9)

VALUE (source page 12, field 10)

VALUE (source page 12, field 11)

ON DEED (source page 12, field 12)

LENDER (source page 12, field 13)

DESCRIPTION (source page 12, field 14)

VALUE (source page 12, field 15)

VALUE (source page 12, field 16)

ON DEED (source page 12, field 17)

LENDER (source page 12, field 18)

IS ANYONE ELSE ON THE DEED OR A CO-OWNER? (source page 12, field 19)

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11
Vehicles
YEAR / MAKE /
MODEL
MILEAGE
EST.
VALUE
LIENHOLDER /
LENDER
LOAN
BALANCE
WHOSE
NAME
12
Bank & Cash Accounts
INSTITUTION
ACCOUNT
TYPE
LAST 4
DIGITS
CURRENT
BALANCE
WHOSE
NAME
List every car, truck, motorcycle, boat, trailer, RV, or other titled vehicle —
even if fully paid off or financed. Gather the title and/or registration and
any loan statement.
List all checking, savings, money-market, prepaid, and credit-union
accounts. Gather statements for the last 6 months for every account.

MODEL (source page 13, field 1)

MILEAGE (source page 13, field 2)

VALUE (source page 13, field 3)

LENDER (source page 13, field 4)

BALANCE (source page 13, field 5)

NAME (source page 13, field 6)

MODEL (source page 13, field 7)

MILEAGE (source page 13, field 8)

VALUE (source page 13, field 9)

LENDER (source page 13, field 10)

BALANCE (source page 13, field 11)

NAME (source page 13, field 12)

MODEL (source page 13, field 13)

MILEAGE (source page 13, field 14)

VALUE (source page 13, field 15)

LENDER (source page 13, field 16)

BALANCE (source page 13, field 17)

NAME (source page 13, field 18)

MODEL (source page 13, field 19)

MILEAGE (source page 13, field 20)

VALUE (source page 13, field 21)

LENDER (source page 13, field 22)

BALANCE (source page 13, field 23)

NAME (source page 13, field 24)

INSTITUTION (source page 13, field 25)

TYPE (source page 13, field 26)

DIGITS (source page 13, field 27)

BALANCE (source page 13, field 28)

NAME (source page 13, field 29)

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CASH ON HAND TODAY
ANY ACCOUNT CLOSED IN THE LAST YEAR?
13
Retirement, Annuities & Investments
TYPE (401K, IRA, PENSION,
ANNUITY, STOCKS,
BONDS, ETC.)
INSTITUTION /
PLAN
APPROX.
VALUE
WHOSE NAME
LIFE INSURANCE — COMPANY, TYPE, FACE AMOUNT, AND ANY CASH VALUE
List retirement and investment holdings — 401(k), IRA, pension, 403(b),
TSP, annuities, stocks, bonds, mutual funds, brokerage accounts,
cryptocurrency, and life insurance with cash value. Many retirement
accounts are protected, but all must be disclosed. Gather recent
statements.

BONDS, ETC.) (source page 14, field 1)

PLAN (source page 14, field 2)

VALUE (source page 14, field 3)

WHOSE NAME (source page 14, field 4)

BONDS, ETC.) (source page 14, field 5)

PLAN (source page 14, field 6)

VALUE (source page 14, field 7)

Response 8 (see source page) (source page 14, field 8)

Response 9 (see source page) (source page 14, field 9)

Response 10 (see source page) (source page 14, field 10)

Response 11 (see source page) (source page 14, field 11)

Response 12 (see source page) (source page 14, field 12)

Response 13 (see source page) (source page 14, field 13)

CASH ON HAND TODAY (source page 14, field 14)

ANY ACCOUNT CLOSED IN THE LAST YEAR? (source page 14, field 15)

BONDS, ETC.) (source page 14, field 16)

PLAN (source page 14, field 17)

VALUE (source page 14, field 18)

WHOSE NAME (source page 14, field 19)

BONDS, ETC.) (source page 14, field 20)

PLAN (source page 14, field 21)

VALUE (source page 14, field 22)

WHOSE NAME (source page 14, field 23)

BONDS, ETC.) (source page 14, field 24)

PLAN (source page 14, field 25)

VALUE (source page 14, field 26)

WHOSE NAME (source page 14, field 27)

BONDS, ETC.) (source page 14, field 28)

PLAN (source page 14, field 29)

VALUE (source page 14, field 30)

Response 31 (see source page) (source page 14, field 31)

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Source page 15 · 7 mapped fields

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14
Other Personal Property
Estimate the resale value of what you own — not replacement cost. Group
ordinary items (e.g., “household furnishings”) and separately list anything
of notable value.
HOUSEHOLD GOODS & FURNISHINGS (TOTAL)
ELECTRONICS (TOTAL)
CLOTHING (TOTAL)
JEWELRY & WATCHES
FIREARMS, SPORTS & HOBBY EQUIPMENT
COLLECTIBLES, ART, ANTIQUES
TOOLS & EQUIPMENT
PETS / LIVESTOCK

HOUSEHOLD GOODS & FURNISHINGS (TOTAL) (source page 15, field 1)

ELECTRONICS (TOTAL) (source page 15, field 2)

CLOTHING (TOTAL) (source page 15, field 3)

JEWELRY & WATCHES (source page 15, field 4)

FIREARMS, SPORTS & HOBBY EQUIPMENT (source page 15, field 5)

COLLECTIBLES, ART, ANTIQUES (source page 15, field 6)

TOOLS & EQUIPMENT (source page 15, field 7)

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ANYTHING ELSE OF VALUE NOT LISTED ELSEWHERE
15
Claims, Lawsuits, Inheritances & Other
Interests
This is one of the most overlooked areas — and the trustee looks closely
at it. Disclose any right to receive money or property, even if uncertain or
in the future: lawsuits or claims you could bring, personal-injury or other
tort actions, insurance claims, tax refunds owed to you, and any
inheritance or trust interest — including one you may receive within 180
days after ﬁling.
LAWSUITS OR LEGAL CLAIMS YOU HAVE OR COULD BRING (AGAINST ANYONE)
PERSONAL-INJURY OR OTHER TORT CLAIMS (CAR ACCIDENT, MALPRACTICE,
INJURY, ETC.)
INSURANCE CLAIMS PENDING OR EXPECTED
TAX REFUNDS OWED TO YOU (FEDERAL, STATE, OR PRIOR YEARS)
INHERITANCE, TRUST, OR ESTATE INTEREST — RECEIVED, PENDING, OR

ANYTHING ELSE OF VALUE NOT LISTED ELSEWHERE (source page 16, field 1)

LAWSUITS OR LEGAL CLAIMS YOU HAVE OR COULD BRING (AGAINST ANYONE) (source page 16, field 2)

INJURY, ETC.) (source page 16, field 3)

INSURANCE CLAIMS PENDING OR EXPECTED (source page 16, field 4)

TAX REFUNDS OWED TO YOU (FEDERAL, STATE, OR PRIOR YEARS) (source page 16, field 5)

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Source page 17 · 39 mapped fields

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,
,
,
,
EXPECTED (INCL. WITHIN 180 DAYS AFTER FILING)
MONEY OWED TO YOU BY ANYONE (LOANS YOU MADE, DEPOSITS, UNPAID
WAGES, JUDGMENTS IN YOUR FAVOR)
INTERESTS IN A BUSINESS, PARTNERSHIP, PATENT, COPYRIGHT, OR ROYALTY
16
Secured Debts
Debts backed by collateral — mortgages, home-equity loans, car loans,
and any loan where you pledged property. Say whether you want to keep
(and keep paying) or surrender the collateral.
CREDITOR
ACCOUNT
#
COLLATERAL
BALANCE
OWED
MONTHLY
PAYMENT
KEEP /
SURRENDER

CREDITOR (source page 17, field 1)

# (source page 17, field 2)

COLLATERAL (source page 17, field 3)

OWED (source page 17, field 4)

PAYMENT (source page 17, field 5)

SURRENDER (source page 17, field 6)

CREDITOR (source page 17, field 7)

# (source page 17, field 8)

COLLATERAL (source page 17, field 9)

OWED (source page 17, field 10)

PAYMENT (source page 17, field 11)

SURRENDER (source page 17, field 12)

EXPECTED (INCL. WITHIN 180 DAYS AFTER FILING) (source page 17, field 13)

WAGES, JUDGMENTS IN YOUR FAVOR) (source page 17, field 14)

INTERESTS IN A BUSINESS, PARTNERSHIP, PATENT, COPYRIGHT, OR ROYALTY (source page 17, field 15)

CREDITOR (source page 17, field 16)

# (source page 17, field 17)

COLLATERAL (source page 17, field 18)

OWED (source page 17, field 19)

PAYMENT (source page 17, field 20)

SURRENDER (source page 17, field 21)

CREDITOR (source page 17, field 22)

# (source page 17, field 23)

COLLATERAL (source page 17, field 24)

OWED (source page 17, field 25)

PAYMENT (source page 17, field 26)

SURRENDER (source page 17, field 27)

CREDITOR (source page 17, field 28)

# (source page 17, field 29)

COLLATERAL (source page 17, field 30)

OWED (source page 17, field 31)

PAYMENT (source page 17, field 32)

SURRENDER (source page 17, field 33)

CREDITOR (source page 17, field 34)

# (source page 17, field 35)

COLLATERAL (source page 17, field 36)

OWED (source page 17, field 37)

PAYMENT (source page 17, field 38)

SURRENDER (source page 17, field 39)

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Source page 18 · 25 mapped fields

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17
Priority Debts — Taxes & Support
Certain debts get priority and usually are not wiped out — recent income
taxes, and domestic support obligations (child support, spousal
support/alimony). List them here.
CREDITOR / AGENCY
/ PERSON
TYPE (TAX, CHILD
SUPPORT,
ALIMONY)
PERIOD /
YEAR
AMOUNT
OWED
BEHIND?
18
Unsecured Debts
Everything else you owe with no collateral — credit cards, medical bills,
personal and payday loans, deﬁciencies, judgments, old utility bills, and
any business debts you are personally liable for. Include amounts and
account numbers.
CREDITOR NAME
ADDRESS
ACCOUNT
#
AMOUNT
OWED
CO-
SIGNED?

/ PERSON (source page 18, field 1)

ALIMONY) (source page 18, field 2)

YEAR (source page 18, field 3)

OWED (source page 18, field 4)

BEHIND? (source page 18, field 5)

/ PERSON (source page 18, field 6)

ALIMONY) (source page 18, field 7)

YEAR (source page 18, field 8)

OWED (source page 18, field 9)

BEHIND? (source page 18, field 10)

/ PERSON (source page 18, field 11)

ALIMONY) (source page 18, field 12)

YEAR (source page 18, field 13)

OWED (source page 18, field 14)

BEHIND? (source page 18, field 15)

/ PERSON (source page 18, field 16)

ALIMONY) (source page 18, field 17)

YEAR (source page 18, field 18)

OWED (source page 18, field 19)

BEHIND? (source page 18, field 20)

CREDITOR NAME (source page 18, field 21)

ADDRESS (source page 18, field 22)

# (source page 18, field 23)

OWED (source page 18, field 24)

SIGNED? (source page 18, field 25)

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Source page 19 · 50 mapped fields

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19
Co-Signers, Guarantors & Co-Debtors
If anyone else is legally responsible for a debt with you — a co-signer,
guarantor, or joint account holder — list them. Filing does not erase a co-
signer’s responsibility, so this affects them directly.
CO-SIGNER /
CO-DEBTOR
NAME
ADDRESS
RELATIONSHIP
WHICH DEBT
AMOUNT

Response 1 (see source page) (source page 19, field 1)

Response 2 (see source page) (source page 19, field 2)

Response 3 (see source page) (source page 19, field 3)

Response 4 (see source page) (source page 19, field 4)

Response 5 (see source page) (source page 19, field 5)

Response 6 (see source page) (source page 19, field 6)

Response 7 (see source page) (source page 19, field 7)

Response 8 (see source page) (source page 19, field 8)

Response 9 (see source page) (source page 19, field 9)

Response 10 (see source page) (source page 19, field 10)

NAME (source page 19, field 11)

ADDRESS (source page 19, field 12)

RELATIONSHIP (source page 19, field 13)

WHICH DEBT (source page 19, field 14)

AMOUNT (source page 19, field 15)

Response 16 (see source page) (source page 19, field 16)

Response 17 (see source page) (source page 19, field 17)

Response 18 (see source page) (source page 19, field 18)

Response 19 (see source page) (source page 19, field 19)

Response 20 (see source page) (source page 19, field 20)

Response 21 (see source page) (source page 19, field 21)

Response 22 (see source page) (source page 19, field 22)

Response 23 (see source page) (source page 19, field 23)

Response 24 (see source page) (source page 19, field 24)

Response 25 (see source page) (source page 19, field 25)

Response 26 (see source page) (source page 19, field 26)

Response 27 (see source page) (source page 19, field 27)

Response 28 (see source page) (source page 19, field 28)

Response 29 (see source page) (source page 19, field 29)

Response 30 (see source page) (source page 19, field 30)

Response 31 (see source page) (source page 19, field 31)

Response 32 (see source page) (source page 19, field 32)

Response 33 (see source page) (source page 19, field 33)

Response 34 (see source page) (source page 19, field 34)

Response 35 (see source page) (source page 19, field 35)

NAME (source page 19, field 36)

ADDRESS (source page 19, field 37)

RELATIONSHIP (source page 19, field 38)

WHICH DEBT (source page 19, field 39)

AMOUNT (source page 19, field 40)

NAME (source page 19, field 41)

ADDRESS (source page 19, field 42)

RELATIONSHIP (source page 19, field 43)

WHICH DEBT (source page 19, field 44)

AMOUNT (source page 19, field 45)

NAME (source page 19, field 46)

ADDRESS (source page 19, field 47)

RELATIONSHIP (source page 19, field 48)

WHICH DEBT (source page 19, field 49)

AMOUNT (source page 19, field 50)

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Source page 20 · 20 mapped fields

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20
Leases & Ongoing Contracts
List apartment or home leases, vehicle leases, rent-to-own, storage, cell-
phone contracts, and any agreement still in force.
OTHER PARTY
WHAT IT COVERS
MONTHLY
PAYMENT
EXPIRES
BEHIND?
21
Lawsuits, Judgments, Garnishments &
Repossessions
Disclose collection activity against you within the last year and anything
pending now — lawsuits, judgments, wage or bank garnishments, tax
levies, repossessions, and foreclosures.
Any lawsuits, judgments, or garnishments against you (now or in the last
year)?
Yes
No
CASE / CREDITOR
COURT /
AGENCY
CASE
NUMBER
TYPE
STATUS

OTHER PARTY (source page 20, field 1)

WHAT IT COVERS (source page 20, field 2)

PAYMENT (source page 20, field 3)

EXPIRES (source page 20, field 4)

BEHIND? (source page 20, field 5)

OTHER PARTY (source page 20, field 6)

WHAT IT COVERS (source page 20, field 7)

PAYMENT (source page 20, field 8)

EXPIRES (source page 20, field 9)

BEHIND? (source page 20, field 10)

OTHER PARTY (source page 20, field 11)

WHAT IT COVERS (source page 20, field 12)

PAYMENT (source page 20, field 13)

EXPIRES (source page 20, field 14)

BEHIND? (source page 20, field 15)

OTHER PARTY (source page 20, field 16)

WHAT IT COVERS (source page 20, field 17)

PAYMENT (source page 20, field 18)

EXPIRES (source page 20, field 19)

BEHIND? (source page 20, field 20)

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Source page 21 · 17 mapped fields

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WAGE OR BANK GARNISHMENTS, TAX LEVIES, OR LIENS IN THE LAST YEAR
PROPERTY REPOSSESSED, FORECLOSED, OR RETURNED IN THE LAST YEAR
22
Recent Payments, Transfers & Financial
Aﬀairs
The trustee reviews money and property that moved before ﬁling. Please
answer each — or write “None.” These mirror the Statement of Financial
Affairs.
a. Payments totaling more than $600 to any one creditor within the 90 days
before ﬁling.
Describe — or None

Response 1 (see source page) (source page 21, field 1)

Response 2 (see source page) (source page 21, field 2)

Response 3 (see source page) (source page 21, field 3)

Response 4 (see source page) (source page 21, field 4)

Response 5 (see source page) (source page 21, field 5)

Response 6 (see source page) (source page 21, field 6)

Response 7 (see source page) (source page 21, field 7)

Response 8 (see source page) (source page 21, field 8)

Response 9 (see source page) (source page 21, field 9)

Response 10 (see source page) (source page 21, field 10)

Response 11 (see source page) (source page 21, field 11)

Response 12 (see source page) (source page 21, field 12)

Response 13 (see source page) (source page 21, field 13)

Response 14 (see source page) (source page 21, field 14)

Response 15 (see source page) (source page 21, field 15)

WAGE OR BANK GARNISHMENTS, TAX LEVIES, OR LIENS IN THE LAST YEAR (source page 21, field 16)

PROPERTY REPOSSESSED, FORECLOSED, OR RETURNED IN THE LAST YEAR (source page 21, field 17)

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Source page 22 · 0 mapped fields

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b. Any payment or transfer to a relative, friend, or business partner (an
“insider”) within the 1 year before ﬁling.
Describe — or None
c. Property sold, transferred, or given away within the last 2 years (other than
ordinary purchases).
Describe — or None
d. Gifts or charitable contributions over $600 within the last 2 years.
Describe — or None
e. Losses from theft, ﬁre, disaster, or gambling within the last year.
Describe — or None
f. Money paid to any attorney, bankruptcy preparer, or credit-counseling
service within the last year.
Describe — or None

Additional answers for source page 22 (including table rows, checklists or items without a separate box)

Source page 23 · 2 mapped fields

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g. Financial accounts closed, sold, or transferred within the last year.
Describe — or None
h. Property you hold for someone else, or that someone else holds for you.
Describe — or None
i. Your total gross income from all sources for this year and the prior 2 years.
Describe — or None
23
Income Tax Information
MOST RECENT FEDERAL RETURN FILED — YEAR
MOST RECENT STATE RETURN FILED — YEAR
ANY UNFILED RETURNS? WHICH YEARS?
Your returns must be filed and current. Confirm what has been filed, what
is owed, and any refund coming to you (a refund is an asset). Gather your
last 2 years of federal and state returns.

MOST RECENT FEDERAL RETURN FILED — YEAR (source page 23, field 1)

MOST RECENT STATE RETURN FILED — YEAR (source page 23, field 2)

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Source page 24 · 3 mapped fields

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TAXES CURRENTLY OWED (FEDERAL / STATE / LOCAL)
REFUND(S) YOU EXPECT OR ARE OWED
ANY TAX LIENS OR LEVIES?
24
Anything Else We Should Know
Use this space for anything not captured above — expected changes,
disputes, concerns, or questions for the attorney. When in doubt, tell us.
25
Document Checklist
Please gather these items and upload them through the secure encrypted
portal, never email. The more complete this is, the faster and smoother your
case will go.

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TAXES CURRENTLY OWED (FEDERAL / STATE / LOCAL) (source page 24, field 1)

REFUND(S) YOU EXPECT OR ARE OWED (source page 24, field 2)

ANY TAX LIENS OR LEVIES? (source page 24, field 3)

Additional answers for source page 24 (including table rows, checklists or items without a separate box)

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