Bankruptcy Questionnaire

Instructions: In order to complete your bankruptcy petition and file your case in a timely manner, please fill out ALL the information as completely and accurate as possible. When your questionnaire is completed in full and submitted. It will be reviewed by one of our associates at Law Office of Steven A. Zipper, P.A. and will contact you with the next step.

How where you referred to this office?

Name

Social Security Number

Date of Birth

Address

Unit

City

State

Zip Code

Phone#

Email

Occupation

How Long Employed

Employer

Work phone number

Are you married?

Spouse Name

Social Security Number

Date of Birth

Address

Unit

City

State

Zip Code

Phone#

Email

Occupation

How Long Employed

Employer

Work phone number

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Do you own a home?

Do you rent a property?

Do you have a mortgage?

If yes, how much do you owe total?

Are taxes and insurance included as part of mortgage payment?

Is there a separate HOA?

Are payments current?

List all mortgages on the above property listed.

Name of First Mortgage Holder:

Address of First Mortgage Holder:

Unit

City

State

Zip Code

Loan Number

How much do you owe on your Second Mortgage?

Do you own any other real estate?

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Please give the requested information for each automobile or motor vehicle in the family:

Car 1:

Make

Model

Year

Value

Amount owed:

To whom:

Monthly payment:

Current?

Leased or owned:

Amount owed:

To whom:

Title held in the name of:

Car 2:

Make

Model

Year

Value

Amount owed:

To whom:

Leased or owned:

Monthly payment:

Current?

Title held in the name of:

Car 3:

Make

Model

Year

Value

Amount owed:

To whom:

Leased or owned:

Monthly payment:

Current?

Title held in the name of:

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Personal property

1.cash on hand (Average amount of money you carry in pocket): $

2. please list all bank accounts, including type of account, account number, amount in account, and name and full address on bank

YOURS:

Checking

Savings

Amount in bank

Bank name:

Account Number

If joint account, with who?

Checking

Savings

Amount in bank

Bank name:

Account Number

If joint account, with who?

Spouse's:

Checking

Savings

Amount in bank

Bank name:

Account Number

If joint account, with who?

Checking

Savings

Amount in bank

Bank name:

Account Number

If joint account, with who?

List all furniture and appliances (estimate at garage sale) and do you owe money on any? please give details:

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4. What is the value (used) of the following items:

Clothing

Yours

$

Spouse

$

Jewelry

$

Firearms

$

Sport Equipment

$

Personal Effects

$

Other property of value (please Described

5. Life insurance policies: SPECIFY IF POLICY IS FOR HUSBAND OR WIFE IF APPLICABLE

Name of policy/company

$

Type of policy: Term

whole

policy number

Name of policy/company

$

Type of policy: Term

whole

policy number

Annuities:

Intrests in pensions or profit sharing plans (ie. 401k or 403b):

Name of plan/company

$

Name of plan/company

$

stock in companies

$

Accounts receivable (does anyone owe you money)

Have you paid back any friends or relative in the last year/If yes, please give details

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Alimony, maintenance, support, property settlements to which you are entitled:

$

Name, age, and relationship of dependants you support:

Name:

Age:

Relationship:

Name:

Age:

Relationship:

Name:

Age:

Relationship:

Name:

Age:

Relationship:

Do you have any student loans outstanding? If yes, with whom:

How much

Do you owe taxes:

if so How much $

Please give details:

How much was your tax refund last year

Do you owe taxes?:

How much?

Do you have any judgements against you?

if yes please give details

Are you currently in foreclosure:

Are you involved in any other legal matters, etc. divorce, personal injury, etc.

OTHER INFO:

PLEASE FILL OUT THE ATTACHED TO YOUR BEST ESTIMATE. SCHEDULE I: YOUR INCOME AND SCHEDULE J: YOUR EXPENSES

UPON YOUR RETURN TO THE OFFICE PLEASE HAVE COPIES OF: LAST 6 MONTHS CHECKING BANK STATEMENTS, LAST 2 YEARS TAX RETURNS, COPY OF LAST 2 MONTHS PAY STUBS, CIOY IF MORTGAGE STATEMENT, COPY OF SOCIAL SECURITY CARD, COPY OF FLORIDA DRIVERS LICENSE AND/OR STATE ID, COPY OF DEBTS TO BE IMCLUDED IN BANKRUPTCY, COPY OF LAWSUITS, ETC