* required
Preferred method of contacting you
Email
Phone
Your marital status:
Never married
Married
Divorced
Widowed
Separated
Number of persons living with you, including yourself, children for whom you pay child support, and anyone else you financially
support:
Why are you considering bankruptcy?
Please provide an explanation below if you would answer "yes" to any of the following questions (more space
is available at the end of the form if you need it) ("you" means you and your spouse if you are married):
1.
Does anyone owe you money?
2. Do you have a reason to file a lawsuit, a disability claim, a workers compensation claim,
an unemployment claim, or a property insurance claim?
3. Do you owe any money to family members?
4. Have you repaid
any money to family members or have you transferred any property (such as cars) to family members in the past two years?
5.
Have you every filed a bankruptcy before?
6. Is anyone else responsible for any of your debts (such as cosigners)?
7.
Is it likely you will inherit in the next year?
8. Are you currently being sued? Are there any judgments against
you from past lawsuits?
9. Are you being garnished at this time?
10. Are you being foreclosed upon?
11.
Are your creditors threatening to repossess automobiles?
12. Do you owe any taxes? Are you late in filing any tax returns?
13. Do you owe any child support?
Indicate below all of the types of income you and your spouse have received in the past seven months.
Wages from employer
Self-employment/business
Social Security
Retirement/pension
Unemployment
Other government assistance
Child support or alimony
Rental or other investment
Other income
Please provide details (such as type of asset and value) below if you would answer "yes" to any of the following
questions:
1. Do you have any retirement savings?
2. Do you have any stocks, bonds, or other investments that
can be cashed out at this time?
3. Do you own a timeshare?
4. Do you own any homes or other real estate other
than the home you are living in?
5. Do you have any life insurance which has cash liquidation value?
6. Do you
own any businesses or business assets?
7. Do you own any valuable animals?
Please provide any other explanations or details you wish below.
