Part A. Name and Address

Part B. Name and Address of Spouse

Part C. Prior/Pending Bankruptcy Cases

Part A. Real Estate (Schedule A)

Part B. Personal Property (Schedule B)

Part A. Name and Address

Part B. Name and Address of Spouse

Part C. Prior/Pending Bankruptcy Cases

Part A. Real Estate (Schedule A)

Part B. Personal Property (Schedule B)

Client Questionnaire For Non-Business Debtor

Section 1 - Basic Information

Section 2 - Property

Section 3 - Debts

Section 4 - Unexpired Leases and Contracts (Schedule G)

Section 5 - Current Income

Client Questionnaire For Non-Business Debtor

Section 1 - Basic Information

Section 2 - Property

Section 3 - Debts

Section 4 - Unexpired Leases and Contracts (Schedule G)

Section 5 - Current Income

Section 7 - Statement of Financial Affairs

Part A. Debtor’s Income

Part B. Joint Debtor’s Income

Name:

Last First Middle

Telephone Number Home: Work:

Have you used any other names in the past six years? q No q Yes If yes, list other names:

Social Security Number: ___ ___ ___ - ___ ___ - ___ ___ ___ ___

Address:

City: State: Zip:

County: Have you lived at this address for at least 180 days? q No q Yes

If you have a different mailing address, please list:

Mailing Address:

City: State: Zip:

If you are filing jointly with your spouse, fill in the following information about your spouse:

Name:

Last First Middle

Has your spouse used any other names in the past six years? q No q Yes If yes, list other names:

Social Security Number: ___ ___ ___ - ___ ___ - ___ ___ ___ ___

Address: (if different from your address):

City: State: Zip: County:

If your spouse has a different mailing address, please list:

Mailing Address:

City: State: Zip:

Has a bankruptcy case been filed by you or against you in the last 6 years? q No q Yes

If yes, in which district of which state was the case filed? _

Case Number: ______ Date filed: _

Are there currently any bankruptcy cases pending against you, your business, your spouse, or your spouse’s business? q No q Yes

If yes, name of debtor: Relationship to you: __

Case Number: ______ Date filed: ______ Judge: ______

In which district of which state was the case filed?

Exhibit "C" to the Voluntary Petition

Do you own or have possession of any property that poses or is alleged to pose a threat of imminent and identifiable harm to public health or safety? q No q Yes (If yes, please attach a list and description of the property.)

List all real estate which you own or are a joint owner of, even if you still owe money on the property.

Address and description of property	Owned by Husband, Wife, Joint or Community	Market Value	Your % ownership, or $ amount, if you and spouse are not sole owners	List all mortgages, home equity loans, and liens: What is the $ value of the loan, lien or mortgage?	Who issued the lien, loan or mortgage? (Name, Address of Institution)	Office Use Only Exemptions?

For each type of property listed below, indicate whether you own any property of that category, and, if you do, fill in the remaining information. You can think of the market value as the resale value.

Type of Property	Yes/ No	Description & Location	Husband, Wife, Joint, Community	Market Value	Office Use Only Exemptions?
1. Cash on hand
2. Checking/Savings Account, Certificates of deposit, other bank accounts
3. Security deposits held by utility companies, landlord
4. Household goods, furniture, including audio, video, and computer equipment
5. Books, pictures, art objects, records, compact discs, collectibles
6. Clothing
7. Furs and jewelry
8. Sports, photographic, hobby equipment, firearms
9. Interest in insurance policies-specify refund or cancellation value
10. Annuities
11. Interests in pension or profit sharing plans
12. Stock and interests in incorporated/ unincorporated business
13. Interests in partnerships/joint ventures
14. Bonds
15. Accounts receivable
16. Alimony/family support to which you are entitled
17. Other liquidated debts owed to you, including tax refunds
18. Equitable or future interests or life estates
19. Interests in estate of descendent or life insurance plan or trust
20. Other contigent/ unliquidated claims, including tax refunds, counterclaims
21. Patents, copyrights, other intellectual property
22. Licenses, franchises
23. Automobiles, trucks, trailers, and accessories.
24. Boats, motors, and accessories
25. Aircraft and accessories
26. Office equipment, supplies
27. Machinery, fixtures etc. for business
28. Inventory
29. Animals
30. Crops-growing or harvested
31. Farming equipment and implements
32. Farm supplies, chemicals, feed
33. Other personal property of any kind not listed.

List below all debts that you owe, or that creditors claim that you owe.

Type of Debt	1. Creditor Name and Address 2. Account Number, if any 3. Date/range of dates when debt was incurred 4. Contact person's name and address, if different	Amount owed	Name and address of codebtor, if any What is debt for? Is debt secured by any property?	Do you dispute the debt?	Office Use Only
Type of Debt		Amount owed		Do you dispute the debt?	Sched D, E or F?	Lawsuit pending? Collection agency assigned? Counsel for creditor?
Home loans/ mortgages
Car loans
Other bank loans
Personal loans
Student loans
Major credit card debts (Visa, Am Ex, Mastercard, Discover) - continue on next page, if necessary
Unpaid credit cards, (Visa, Am Ex, Mastercard, Discover) *continued*
Department store credit card debts
Other credit card debts (Gas cards, phone cards, etc.)
Unpaid medical bills
Unpaid utility bills
Unpaid rent
Unpaid taxes
Unpaid alimony or child support
Unpaid service fees
All other unpaid debts/bills

List below any leases or contracts that are still current that you are a party to. Include residential, car and business leases, and service or business contracts.

Nature and Description of Contract	Name and Address of Other Party or Parties	Date that Contract Expires

Section 6 - Current Expenses

Do you and your spouse maintain separate households? q No q Yes. If so, fill one page out for your household and another for your spouse’s.

The following questions ask for your expenses each month. If you are unsure of the amount you pay each month, but know the amount for a different period (per week, per day, every 2 months, etc.,), write in the amount and the frequency that you pay the amount.

Indicate how much you pay for each item each month…

1. your rent or your home mortgage $_________________

Does that amount include real estate taxes? q No q Yes

Does it include property insurance? q No q Yes

2. electricity and heating $_________________

3. water and sewage $_________________

4. telephone service/long distance $_________________

5. Do you have any other utility bills? If so, what, and how much per month?

__________________________________________________ $_________________

6. home maintenance, including repairs and general upkeep $_________________

7. food $_________________

8. clothing $_________________

9. laundry and dry cleaning $_________________

10. medical and dental expenses $_________________

11. transportation (not including car payments) $_________________

12. entertainment, recreation, newspapers, magazines $_________________

13. charitable contributions $_________________

14. insurance not deducted from paycheck

a) homeowner’s or renter’s insurance $_________________

b) life insurance $_________________

c) health insurance $_________________

d) auto insurance $_________________

e) other insurance_______________________ $_________________

15. taxes not deducted from paycheck $_________________

16. installment payments for car, furniture, etc. (Specify)

__________________________________________________ $_________________

17. alimony, maintenance, support paid to others $_________________

18. payments for support of dependents not living at home $_________________

19. expenses from operation of business $_________________

20. other expenses not listed above __________________________ $_________________

_________________________________________________ $_________________

Section 7 - Statement of Financial Affairs

If you are filing jointly with your spouse, include information about both you and your spouse. If you are filing under chapter 12 or 13, and you are married and not separated, you must provide information about your spouse even if you are not filing jointly.

State your gross income from employment or operation of a business: If you have not received an income from employment during the two years immediately preceding this calendar year, check this box:

State the amount of income received other than from employment or operation of business during the two years immediately preceding the commencement of this case:

a. List all payments on loans, installment purchases of goods or services, and other debts, aggregating more than $600 to any creditor made within 90 days immediately preceding the commencement of this case.

b. List all payments made within one year immediately preceding the commencement of this case to creditors who were "insiders". ("Insiders" include your relatives, your business partners and their relatives, your corporations, or your affiliates.)

a. List all suits and administrative proceedings to which you are or were a party within one year preceding the filing of this case.

b. Describe all property that has been garnished, seized, or attached under any legal or equitable process within one year immediately preceding the commencement of this case.

for Whom the Property Was Seized (Creditor) Date of Seizure and Value of Property

List all property that has been repossessed by a creditor, sold at a foreclosure sale, transferred through a deed in lieu of foreclosure, or returned to the seller, within one year immediately preceding the commencement of this case.

Name and Address of Creditor Foreclosure, Transfer or Return and Value of Property

a. Describe any assignment of property for the benefit of creditors made within 120 days immediately preceding the commencement of this case.

b. List all property which has been in the hands of a custodian, receiver, or court-appointed official within one year immediately preceding the commencement of this case.

List all gifts or charitable contributions made within one year immediately preceding the commencement of this case except ordinary and usual gifts to family members aggregating less than $200 in value per individual family member and charitable contributions aggregating less than $100 per recipient.

List all losses from fire, theft, gambling or other casualty within one year immediately preceding the commencement of this case or since the commencement of this case.

List all payments made or property transferred by or on behalf of the debtor to any persons, including attorneys, for consultation concerning debt consultation, relief under the bankruptcy law or preparation of the petition in bankruptcy within one year immediately preceding the commencement of the case.

List all other property, other than property transferred in your ordinary course of business or financial affairs, transferred either absolutely or as a security within one year immediately preceding the commencement of this case.

List all financial accounts and instruments held in your name or for your benefit which were closed, sold, or otherwise transferred within one year immediately preceding the commencement of this case.

List each safe deposit or other box or depository in which you have or have had securities, cash, or other valuables within one year immediately preceding commencement of this case.

Bank or Other Depository With Access to Box or Depository of Contents Transfer, if Any

List all setoffs made by any creditor, including a bank, against a debt or deposit of yours within 90 days preceding the commencement of this case.

Name and Address of Owner Description and Value of Property Location of Property

If you have moved within the two years immediately preceding the commencement of this case, list all residences during the last two years, excluding your present address.

If you reside or resided in a community property state, commonwealth, or territory (including Alaska, Arizona, California, Idaho, Louisiana, Nevada, New Mexico, Puerto Rico, Texas, Washington, or Wisconsin) within the six-year period immediately preceding the commencement of the case, identify the name of your spouse and of any former spouse who resides or resided with you in the community property state.

"Environmental Law" means any federal, state, or local statute or regulation regulating pollution, contamination, releases of hazardous or toxic substances, wastes or material into the air, land, soil, surface water, groundwater, or other medium, including, but not limited to, statutes or regulations regulating the cleanup of these substances, wastes, or material.

"Site" means any location, facility, or property as defined under any Environmental Law, whether or not presently or formerly owned or operated by the debtor, including, but not limited to, disposal sites.

"Hazardous Material" means anything defined as a hazardous waste, hazardous substance, toxic substance, hazardous material, pollutant, or contaminant or similar term under an Environmental Law

a. List the name and address of every site for which you received notice in writing by a governmental unit that it may be liable or potentially liable under or in violation of an Environmental Law. Indicate the governmental unit, the date of the notice, and, if known, the Environmental Law:

b. List the name and address of every site for which you provided notice to a governmental unit of a release of Hazardous Material. Indicate the governmental unit to which the notice was sent and the date of the notice.

c. List all judicial or administrative proceedings, including settlements or orders, under any Environmental Law with respect to which you are or were a party. Indicate the name and address of the governmental unit that is or was a party to the proceeding, and the docket number.

a. If the debtor is an individual, list the names, addresses, taxpayer identification numbers, nature of the businesses, and beginning and ending dates of all businesses in which the debtor was an officer, director, partner, or managing executive of a corporation, partnership, sole proprietorship, or was a self-employed professional within the six years immediately preceding the commencement of this case, or in which the debtor owned 5 percent or more of the voting or equity securities within the six years immediately preceding the commencement of this case.

If the debtor is a partnership, list the names, addresses, taxpayer identification numbers, nature of the businesses, and beginning and ending dates of all businesses in which the debtor was a partner or owned 5 percent or more of the voting or equity securities, within the six years immediately preceding the commencement of this case.

If the debtor is a corporation, list the names, addresses, taxpayer identification numbers, nature of the businesses, and beginning and ending dates of all businesses in which the debtor was a partner or owned 5 percent or more of the voting or equity securities within the six years immediately preceding the commencement of this case.

b. Identify any business listed in response to subdivision a., above, that is "single asset real estate" as defined in 11 U.S.C. § 101.

The following questions, #19-25, are only to be answered if you are a corporation or partnership or if you have been, in the six years immediately preceding this case, an officer, director, managing executive, or owner of more than 5% of the voting securities of the corporation; a partner, other than a limited partner, of a partnership; a sole proprietor, or otherwise self-employed.

a. List all bookkeepers and accountants who, within the six years immediately preceding the filing of this bankruptcy case, kept or supervised the keeping of books of account and records.

b. List all firms or individuals who, within the two years immediately preceding the filing of this bankruptcy case, have audited the books of account and records, or prepared a financial statement of the debtor.

c. List all firms or individuals who, at the time of the commencement of this case, were in possession of your books of account and records. If the records are not available, explain.

d. List all financial institutions, creditors and other parties, including mercantile and trade agencies, to whom a financial statement was issued by the debtor within two years immediately preceding the commencement of this case.

a. List the dates of the last two inventories taken of your property, the name of the person who supervised the taking of each inventory, and the dollar amount and basis of each inventory.

b. List the name and address of the person possessing the records of each of the two inventories reported in a.) above.

a. If your business is a partnership, list the nature and percentage of partnership interest of each member of the partnership.

b. If your business is a corporation, list all officers and directors of the corporation, and each stockholder who directly or indirectly owns, controls, or holds 5 % or more of the voting securities of the corporation.

a. If your business is a partnership, list each member who withdrew from the partnership within one year immediately preceding the commencement of this case.

b. If your business is a corporation, list all officers or directors whose relationship with the corporation terminated within one year immediately preceding the commencement of this case.

If your business is a partnership or corporation, list all withdrawals or distributions credited or given to an insider, including compensation in any form, bonuses, loans, stock redemptions, options exercised and any other perquisite during one year immediately preceding the commencement of this case.

Name and Address of Date and Purpose Amount of Money or Description Recipient, and Relationship to You of Withdrawal and Value of Property

If the debtor is a corporation, list the name and federal taxpayer identification number of the parent corporation of any consolidated group for tax purposes of which the debtor has been a member at any time within the six-year period immediately preceding the commencement of the case.

If the debtor is not an individual, list the name and federal taxpayer identification number of any pension fund to which the debtor, as an employer, has been responsible for contributing at any time within the six-year period immediately preceding the commencement of the case.

Marital Status:

q Married

q Single

q Divorced

q Separated

q Widowed

List all dependents of you and your spouse, their ages, and their relationship to you:

Relationship

Part A. Debtor’s Income

Part B. Joint Debtor’s Income

1   What is your occupation? ________________

2   Name and address of your employer:

_______________________________________

_______________________________________

_______________________________________

3   How long have you been employed there?_____

4   What is the gross amount of your paycheck,before taxes, other deductions are taken out? $_______

5   How often do you get paid?     q once a week          q every two weeks                  q twice a month                         q once a month       q other_________________

6   Do you receive overtime pay outside of your salary? If so, how much per month?   $________

7   How much is taken out of each paycheck for taxes and social security?   $___________

8   How much is taken out for insurance? $_______

9   How much for union dues?   $________

10. Are there other deductions? If so, what are they and how much? __________________________

Do you receive

a)      income from business operations outside of your regular paycheck listed above? If so, what is the business and how much do you receive per month?

b)      income from real estate property? If so, how much per month?     qNo   qYes $_________

c)      interest or dividends? If so, how much per month?     qNo qYes   $_________

d)      alimony or family support payments for your use or for the care of your dependents? If so, how much per month?     qNo qYes $_________

e)      social security or other forms of monetary government assistance? qNo qYes $__ ___

f)       retirement or pension money? qNo qYes$____

Do you have any other sources of income not listed?

1. What is your spouse’s occupation?__________

2. Name and address of your spouse’s employer:

_____________________________________

_____________________________________

_____________________________________

3. How long employed there? _________________

4. What is the gross amount of your spouse’s paycheck, before taxes/other deductions? $_____

5. How often does your spouse get paid?     q once a week      q every two weeks     q twice a month    q once a month q other_______

6. Does your spouse receive overtime pay outside of your salary? How much per month? $_______

7. How much is taken out of each paycheck for taxes and social security?   $___________

8. How much is taken out for insurance? $_______

9. How much for union dues?   $________

10. Are there other deductions? If so, what are they and how much? __________________________

Does your spouse receive

a)      income from business operations outside of the regular paycheck listed above? If so, what is the business and how much does your spouse receive per month?

b)      income from real estate property? If so, how much per month?     qNo   qYes   $________

c)      interest or dividends? If so, how much per month?     qNo qYes   $_________

d)      alimony or family support payments for spouse’s use or for care of dependents? If so, how much per month? qNo qYes $_______

e)      social security or other forms of monetary government assistance? qNo qYes $_______

f)       retirement or pension money? qNo qYes$____

Does your spouse have any other income not listed?

Are you or your spouse expecting any increase or decrease in salary of more than 10% next year? If so, explain.