BANKRUPTCY WORKSHEET

DEBTOR INFORMATION
Name First Last
Mailing Address
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country
Street Address
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country

If different from your mailing address.
County
County
Home Phone - (###) - ### ####
Work Phone - (###) - ### ####
Fax - (###) - ### ####
(if available)
Social Security #
Other Tax ID's
Marital Status
Age
Occupation
Length of Employment
Employer Name
Employer Address
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country
Current montly Gross Wages, Salary, Commisions $ . Dollars Cents
(pro-rate if not paid monthly)
Estimated Monthly Overtime $ . Dollars Cents
Payroll Taxes and Social Security Deducted $ . Dollars Cents
Insurance Deducted $ . Dollars Cents
Union Dues Collected $ . Dollars Cents
Dependents. For each dependent, please list (1) Name (2) Age (3) Relationship
What other Personal or Business names have you used in the last 6 years?
Prior Bankruptcies

If you have preciously filed a bankruptcy petition, please list the (1) case number, (2) date and (3) location where you filed
Pending Bankruptcies

If any immediate family member or business partner has a bankruptcy pending please list the (1) case number, (2) name of debtor, (3) relationship to you & (4) location where filed
JOINT DEBTOR INFORMATION
Name First Last
Mailing Address
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country
County
Street Address
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country

If different from mailing address.
County
Home Phone - (###) - ### ####
Work Phone - (###) - ### ####
Fax - (###) - ### ####
If available
Social Security #
Other Tax I.D.'s
Marital Status
Age
Occupation
Length of Employment
Employer Name
Employer Address
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country
Current monthly Gross Wages, Salary, Commissions $ . Dollars Cents
(pro-rate if not paid monthly)
Estimated monthly overtime $ . Dollars Cents
Payroll Taxes and Social Security Deducted $ . Dollars Cents
Insurance Deducted $ . Dollars Cents
Union Dues collected $ . Dollars Cents
What other Personal or Business names have you used in the last 6 years?
Prior Bankruptcies

If you have previously filed a bankruptcy petition, please list the (1) case number, (2) date and (3) location where you filed.
Pending Bankruptcies

If any immediate family member or business partner has a bankruptcy pending please list the (1) case number, (2) name of debtor, (3) relationship to you & (4) location where filed.
YOUR PROPERTY

Real Property is land and things permanently attached to land. Included are unimproved land, vacation duplexes, rental property, business property, mobile home park spaces, agricultural land, airplane hangar permanently attached to land. It also includes property you are entitled to by a trust and all property in equitable, or future interest. If you are in a community property state, your spouse's real estate is also owned. (Time shares should be listed on the worksheet for Schedule G).
** For each question below please include: (1) Who Owns it, (2) Market Value, (3) Your Ownership %, and (4) if it is exempt.
Real Estate (Schedule A)
Personal Property (Schedule B)
Cash on Hand (Indicate Source)
Deposits of Money
Security Deposits
Household Goods, Supplies & Furnishing
Books, Pictures, Art Objects, Stamp, Coin & Other Collections
Wearing Apparel
Jewelry
Fire Arms, Sports & Hobby Equipment
Interests in Insurance Policies
Annuities
Pension or Profit Sharing
** For each question below please include: (1) Who owns it, (2) Market Value, (3) Your ownership %, and (4) If it is exempt.
Stock Interests in Incorporated and Unincorporated Companies
Interests in Partnerships
Government and Corporate Bonds and other Negotiable and non-Negotiable instruments
Accounts Receivable
Family Support (to which you are or may be entitled)
Other liquidated debts owing debtor, including Tax Refunds
Equitable and Future Interests, Life Estates, and Right or Powers
Interest in an Estate of a decedent
Other contingent and unliquidated claims
Patents, Copyrights and other Intellectual Property
Licenses, Franchises, and other General Intangibles
Automobiles, Trucks, Trailers, and other vehicles
Boats, Motors, and accessories
Aircraft and Accessories
Office equipment, furnishing, and supplies
Machinery, fixtures, equipment, and supplies
Inventory
Livestock, poultry, and other animals
Crops
Farming equipment and implements
Farm supplies, chemicals and feed
Other personal property
YOUR DEBTS - SECURED AND PRIORITY
** Please include (1) Account # (2) Who is liable, (3) Market value of property, (4) Balance, (5) Anyone else who is liable. If so, list Name & Address
Mortgage(s) on principal residence
Automobile loans
List other secured debts
Federal taxes (due)
State taxes (Due)
YOUR DEBTS - UNSECURED
** Please include (1) Account # (2) Date incurred. Please Describe debts, (3) Who is liable, (4) balance owed, (5) Anyone else liable. If so, please provide Name and Address
List all unsecured debts
YOUR EXPENSES
Rent or home mortgage payment $ . Dollars Cents
Please state if rent or mortgage payment amount includes Real Estate taxes and/or property insurance
Electricity and heating fuel (monthly average) $ . Dollars Cents
Water and sewer (average monthly) $ . Dollars Cents
Telephone (average monthly) $ . Dollars Cents
Other utilities $ . Dollars Cents
** END. Please click the "continue" button below to submit this form

BANKRUPTCY WORKSHEET

BANKRUPTCY WORKSHEET

DEBTOR INFORMATION

JOINT DEBTOR INFORMATION

YOUR PROPERTY

** For each question below please include: (1) Who Owns it, (2) Market Value, (3) Your Ownership %, and (4) if it is exempt.

** For each question below please include: (1) Who owns it, (2) Market Value, (3) Your ownership %, and (4) If it is exempt.

YOUR DEBTS - SECURED AND PRIORITY

** Please include (1) Account # (2) Who is liable, (3) Market value of property, (4) Balance, (5) Anyone else who is liable. If so, list Name & Address

YOUR DEBTS - UNSECURED

** Please include (1) Account # (2) Date incurred. Please Describe debts, (3) Who is liable, (4) balance owed, (5) Anyone else liable. If so, please provide Name and Address

YOUR EXPENSES

** END. Please click the "continue" button below to submit this form