BASIC CONTACT INFORMATION

    DATE:

    FULL NAME:

    EMAIL:

    ADDRESS:

    CITY:

    ZIP CODE:

    TELEPHONE:

    BEST WAY TO REACH YOU:
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    HOW DID YOU BECOME AWARE OF OUR OFFICE?
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    FINANCIAL QUESTIONNAIRE

    I. GENERAL INFORMATION
    CIVIL STATUS:

    SPOUSE NAME (if applicable):

    IS YOUR SPOUSE THINKING OF FILING FOR BANKRUPTCY ALSO?

    HAVE YOU OR YOUR SPOUSES FILED FOR BANKRUPTCY IN THE PAST?

    YOUR SOCIAL SECURITY NUMBER:

    YOUR SPOUSE SOCIAL SECURITY NUMBER: (write none if not applicable)

    YOUR DATE OF BIRTH:

    YOUR SPOUSE DATE OF BIRTH:

    HAVE YOU LIVED IN THE STATE OF FLORIDA FOR THE PAST 2 YEARS?

    II. REAL PROPERTY

    IN THE LAST TEN (10) YEARS HAVE YOU OWNED OR PARTIALLY OWNED ANY REAL PROPERTY (ex. HOUSE, TOWNHOUSE, APARTMENT, LAND, TIMESHARE OR LOT, TIME SHARE)?

    If Yes, how many?

    DO YOU CURRENTLY OWN A HOME?

    HOW MANY PROPERTIES DO YOU LEGALLY OWN?

    PRIMARY RESIDENCE ADDRESS:

    DO YOU WANT TO KEEP THIS PROPERTY?

    DO YOU LIVE IN THIS HOME?

    WHEN DID YOU PURCHASE IT?

    HOW MUCH IS THE HOME WORTH TODAY IF YOU WERE TO SELL IT?

    HOW MUCH DO YOU OWE IN THE HOME?

    MONTHLY PAYMENTS INCLUDING TAXES AND INSURANCE?

    ARE YOU CURRENT WITH THE PAYMENTS?

    If No, since when?

    ADDRESS OF SECONDARY PROPERTY: (write none if not applicable)

    DO YOU WANT TO KEEP THIS PROPERTY?

    HOW MUCH IS THE PROPERTY WORTH TODAY IF YOU WERE TO SELL IT?

    HOW MUCH DO YOU OWE IN THE PROPERTY?

    MONTHLY PAYMENTS INCLUDING TAXES AND INSURANCE?

    ARE YOU CURRENT WITH THE PAYMENTS?

    If No, since when?

    ADDRESS OF OTHER REAL PROPERTIES: (if applicable)

    III. PERSONAL PROPERTY

    HOW MANY VEHICLES DO YOU OWN?

    IF YES WHAT YEAR AND MODEL ARE THE VEHICLES?

    ARE THEY LEASED, FINANCED OR PAID IN FULL?

    HOW MUCH DID YOU PAY FOR EACH VEHICLE?

    HOW MUCH DO YOU OWE NOW?

    HOW MUCH IS THE MONTHLY PAYMENT?

    HOW LONG WAS IT FINANCED FOR?

    HOW MUCH IS IT WORTH IF YOU WERE TO SELL IT?

    DO YOU HAVE ANY BANK ACCOUNTS, SAVINGS OR CHECKING?

    TYPE OF ACCOUNT / BALANCE:

    IV. EMPLOYMENT

    ARE YOU CURRENTLY EMPLOYED?
    YesNo

    IS YOUR SPOUSE CURRENTLY EMPLOYED: (if applicable)
    YesNo

    NAME OF YOUR EMPLOYER:

    HOW OFTEN DO YOU GET PAY?
    WeeklyBi-WeeklyMonthly

    MONTHLY INCOME:

    YEARLY INCOME

    HOW MUCH DID YOU EARN LAST YEAR?

    NAME OF YOUR SPOUSES EMPLOYER:

    HOW OFTEN DOES YOUR SPOUSE GET PAID?
    WeeklyBi-WeeklyMonthly

    MONTHLY INCOME:

    YEARLY INCOME:

    HOW MUCH DID YOU EARN LAST YEAR?

    V. HOUSEHOLD

    NUMBER OF PEOPLE IN THE HOUSEHOLD:

    NAME THOSE PEOPLE:

    CONTRIBUTION TO HOUSEHOLD:

    VI. CREDITORS

    HOW MANY CREDIT CARDS DO YOU HAVE?

    DO YOU HAVE ANY MEDICAL BILLS OUTSTANDING?
    YesNo

    ARE YOU BEING SUED BY ANYONE?
    YesNo

    LIST NAME AND AMOUNTS OWED TO ALL YOUR CREDITORS/AMOUNT:

     

    §527 (b) DISCLOSURE

    IMPORTANT INFORMATION ABOUT BANKRUPTCY ASSISTANCE SERVICES FROM AN ATTORNEY OR BANKRUPTCY PETITION PREPARER

    If you decide to seek bankruptcy relief, you can represent yourself, you can hire an attorney to represent you, or you can get help in some localities from a bankruptcy petition preparer who is not an attorney. THE LAW REQUIRES AN ATTORNEY OR BANKRUPTCY PETITION PREPARER TO GIVE YOU A WRITTEN CONTRACT SPECIFYING WHAT THE ATTORNEY OR BANKRUPTCY PETITION PREPARER WILL DO FOR YOU AND HOW MUCH IT WILL COST. Ask to see the contract before you hire anyone.

    The following information helps you understand what must be done in a routine bankruptcy case to help you evaluate how much service you need. Although bankruptcy can be complex, many cases are routine.

    Before filing a bankruptcy case, either you, your bankruptcy preparer or your attorney should analyze your eligibility for different forms of debt relief of debt relief available under the Bankruptcy Code and which form of relief is most likely to be beneficial for you. Be sure you understand the relief you can obtain and its limitations. To file a bankruptcy case, documents called a Petition, Schedules, and Statement of Financial Affairs, as well as in some cases a Statement of Intention need to be prepared correctly and filed with the bankruptcy court. You will have to pay a filing fee to the bankruptcy court. Once your case starts, you will have to attend the required first meeting of creditors where you may be questioned by a court official called a “trustee” and by creditors.

    If you choose to file a Chapter 7 case, you may be asked by a creditor to reaffirm a debt. You may want help deciding whether to do so. A creditor is not permitted to coerce you into reaffirming your debts.

    If you choose to file a Chapter 13 case in which you repay your creditors what you can afford over 3 to 5 years, you may also want help with preparing your Chapter 13 plan and with the confirmation hearing on your plan which will be before a bankruptcy judge.

    If you select another type of relief under the Bankruptcy Code other than Chapter 7 or Chapter 13, you will want to find out what should be done from someone familiar with that type of relief.

    Your bankruptcy case may also involve litigation. You are generally permitted to represent yourself in litigation in bankruptcy court, but only attorneys, not bankruptcy petition preparers, can give you legal advice.

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    Client                                                     Date

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    Client                                                     Date

    Download disclosure file here…

    DOWNLOAD PRINTABLE FORM HERE
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