Bankruptcy Questionnaire Template

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Bankruptcy Questionnaire
This questionnaire is also available in English and Spanish versions, in both Microsoft Word
and Adobe Acrobat (PDF) format, on this manual’s companion website. Use the PDF format if you
wish to reprint the questionnaire, and the Word format if you want to edit the document using your
word-processing program.
Bankruptcy is a right provided by law to people who are deeply in debt and in need of a fresh
start. Bankruptcy will discharge many of your debts and you will not have to pay them, except that
mortgages and other liens may still need to be paid if you want to keep the secured property.
The law allows you to keep some money and most types of necessary property in bankruptcy.
To receive this protection, it is necessary that you list all items asked for in the following questions: if
you do not list an item, that item will not be protected in bankruptcy.
You must also list everyone to whom you owe money. If you leave out one of your creditors,
you may have to pay the money owed to that creditor or you may lose your right to a bankruptcy
discharge. It may also be considered a crime if you intentionally give false information or leave out
information.
If you have any questions about whether you can keep certain property or whether you should
list a debt, write that question down and remember to ask the lawyer. We know this questionnaire is
long. Preparing your bankruptcy papers properly takes a significant amount of time and a great deal of
information. If we work together to do so, we can protect your family from great hardship and give you
the new start the law intends you to have.
There is a filing fee of $306 which must be paid to the court in chapter 7 cases, and $281 if your
case is filed under chapter 13. If you do not have the money at the time you file, the court may allow
you up to four months to pay the fee in installments. If you are unable to pay the filing fee even in
installments, you may request that the court waive the filing fee. This right to request a filing fee waiver
applies only in chapter 7 cases. Some of the information requested on this questionnaire will be needed
to prepare a request to waive the filing fee. If you do not request a filing fee waiver or the court does not
approve your request, you must pay the filing fee to get a discharge.
You must also receive budget and credit counseling from an approved credit counseling agency
within 180 days before your case is filed. It is usually a good idea for you to meet with us before you
receive the credit counseling. We can provide you with a list of approved credit counseling agencies.
Different agencies provide the counseling in-person, by telephone, or over the Internet. You should fill
out this questionnaire before meeting with the credit counseling agency and refer to it as needed. You
will need to get from the agency a certificate showing that you received the counseling before your
bankruptcy case was filed, unless the agency provides the certificate to us directly.
Most approved agencies charge between $20–$50 for the pre-filing counseling. However, the
law requires approved agencies to provide bankruptcy counseling and the necessary certificates without
considering an individual’s ability to pay. If you cannot afford the fee, you should ask the agency to
provide the counseling free of charge or at a reduced fee.
After your case is filed, you will need to attend a meeting with the bankruptcy trustee and you
may have to appear at a court hearing. Before the court will give you a discharge, you must also
complete an approved course in personal finances. This course will take approximately two hours to
Bankruptcy Questionnaire
This questionnaire is also available in English and Spanish versions, in both Microsoft Word
and Adobe Acrobat (PDF) format, on this manual’s companion website. Use the PDF format if you
wish to reprint the questionnaire, and the Word format if you want to edit the document using your
word-processing program.
Bankruptcy is a right provided by law to people who are deeply in debt and in need of a fresh
start. Bankruptcy will discharge many of your debts and you will not have to pay them, except that
mortgages and other liens may still need to be paid if you want to keep the secured property.
The law allows you to keep some money and most types of necessary property in bankruptcy.
To receive this protection, it is necessary that you list all items asked for in the following questions: if
you do not list an item, that item will not be protected in bankruptcy.
You must also list everyone to whom you owe money. If you leave out one of your creditors,
you may have to pay the money owed to that creditor or you may lose your right to a bankruptcy
discharge. It may also be considered a crime if you intentionally give false information or leave out
information.
If you have any questions about whether you can keep certain property or whether you should
list a debt, write that question down and remember to ask the lawyer. We know this questionnaire is
long. Preparing your bankruptcy papers properly takes a significant amount of time and a great deal of
information. If we work together to do so, we can protect your family from great hardship and give you
the new start the law intends you to have.
There is a filing fee of $306 which must be paid to the court in chapter 7 cases, and $281 if your
case is filed under chapter 13. If you do not have the money at the time you file, the court may allow
you up to four months to pay the fee in installments. If you are unable to pay the filing fee even in
installments, you may request that the court waive the filing fee. This right to request a filing fee waiver
applies only in chapter 7 cases. Some of the information requested on this questionnaire will be needed
to prepare a request to waive the filing fee. If you do not request a filing fee waiver or the court does not
approve your request, you must pay the filing fee to get a discharge.
You must also receive budget and credit counseling from an approved credit counseling agency
within 180 days before your case is filed. It is usually a good idea for you to meet with us before you
receive the credit counseling. We can provide you with a list of approved credit counseling agencies.
Different agencies provide the counseling in-person, by telephone, or over the Internet. You should fill
out this questionnaire before meeting with the credit counseling agency and refer to it as needed. You
will need to get from the agency a certificate showing that you received the counseling before your
bankruptcy case was filed, unless the agency provides the certificate to us directly.
Most approved agencies charge between $20–$50 for the pre-filing counseling. However, the
law requires approved agencies to provide bankruptcy counseling and the necessary certificates without
considering an individual’s ability to pay. If you cannot afford the fee, you should ask the agency to
provide the counseling free of charge or at a reduced fee.
After your case is filed, you will need to attend a meeting with the bankruptcy trustee and you
may have to appear at a court hearing. Before the court will give you a discharge, you must also
complete an approved course in personal finances. This course will take approximately two hours to
complete. We will give you a list of organizations that provide approved courses. In a chapter 7 case,
you should sign up for the course soon after your case is filed. If you file a chapter 13 case, we will
discuss with you later when you should take the course.
(1) Fill out every question on all of the pages. Wherever you are given a choice of YES or NO
on these forms, check either YES or NO, whichever is correct. Please fill out these pages as well as you
can. We will help with any questions you don’t understand.
(2) Write clearly or typewrite your answers. We must be able to read them.
(3) Wherever the name of a person or firm is asked for, give the full address. Make the address
accurate. Your discharge from each debt depends upon your giving a complete and correct address.
(4) If you do not know the exact amount you owe, fill in a HIGH estimate. Do not leave the
amount blank and do not say “don’t know.” If you dispute owing a debt or the amount claimed, still list
the debt and note that it is disputed.
(5) Wherever you need more room, turn the page over and put the information on the back
together with the number of the question.
(6) List every creditor and everybody that has had anything to do with your debts, including
cosigners. Please include accurate account numbers. If a bill you owe has been sent to a collection
agency or any attorney, list both the person you originally owed and the collection agency or any
attorney, giving the full address of each. If the collection agency has an attorney, list the person you
originally owed, the collection agency, and the attorney, giving the full address of each.
(7) Whenever a question asks you to be prepared to give details, gather all papers concerning the
matter, including bills and collection letters, and bring them with you when you return this form. In any
event, be sure to bring with you the following items (unless they don’t apply to you):
(a) Picture identification card and Social Security card or other document containing your social
security number;
(b) Deeds and mortgages on your house or other real estate, including any agreements you later
entered into to modify any mortgage loans;
(c) Any insurance policies;
(d) Any papers relating to past bankruptcies you or your spouse have filed or that concerned any
of your property, including chapter 13 cases;
(e) Copies of your tax returns for the past four years;
(f) Copies of your pay check stubs for the last sixty days (and you should keep all pay stubs you
receive until your bankruptcy case is over) and any proof of your income and your spouse’s income for
the past six months (such as pay stubs for the entire period, pay stubs which list year-to-date income, or
W-2 statements);
(g) Copies of your last several statements for each bank, credit union, and investment or
brokerage account, and copies of statements for any retirement or savings accounts, including IRAs,
Roth IRAs, education IRAs, 401(k)s, tuition credit programs and medical savings plans (and you should
keep the first bank statement you receive after your case is filed as we may need to provide it to the
trustee);
(h) Legal papers, lawsuits, foreclosure notices, tax sale notices, repossession notices,
garnishment notices, eviction notices, divorce papers, separation agreements, alimony orders, and child
support orders;
(i) Notices of federal tax lien, notices of levy, or other collection notices from the Internal
Revenue Service (IRS) or state or local taxing authorities;
(j) If your mortgage is in foreclosure, any notices you received from your mortgage company or
its attorney showing the total amount you owe, the amount needed to get current, and the date of any
scheduled foreclosure sale;
(k) Any notices informing you that a new company has taken over the ownership or servicing of
your mortgage;
(l) Any appraisals or tax assessment papers;
(m) Any other papers you have concerning any of your debts;
(n) Any lease or installment sale (“lease purchase” or “rent-to-own”) agreements for housing
(apartment, house, mobile home) or other property (cars, televisions, etc.) that you have signed and that
are still in effect or not fully paid; and
(o) Any documents showing that someone else regularly contributes to your household expenses.
Complete All Questions. If you and your spouse are not living together, and there is no possibility that your spouse
will file bankruptcy along with you, you don't have to answer the questions about your spouse.
1.
Name and Residence Information:
A.
Your full name:
Your spouse’s full name:
B.
Your Social Security Number:
Your spouse’s Social Security Number:
C.
Your date of birth and age:
Your spouse’s date of birth and age:
D.
List any other names used by you or your spouse (including maiden name), or other ways you have signed your
names to papers and checks during the last eight years:
E.
Current Address:
(Street)
(City)
(County)
(Zip Code)
F.
Telephone Number:
G. List all addresses you have had in the last three years, the dates when you lived there, and the name you used
while living there. If you and your spouse are filing bankruptcy together, list addresses for each for the last
three years (include street, town, and zip code).
Addresses
Date Moved In
Date Moved Out
Name Used
2.
Prior Bankruptcy:
Have you or your spouse ever been involved before in a bankruptcy (chapter 7, 11, 12, or 13)?
YES___ NO___. If YES, bring all papers from the case(s) to our office.
If Dismissed, List
What
Did You Get
If Yes, List Date
Date and Reason
Chapter?
Date Case Filed
a Discharge?
of Discharge
Why Dismissed
3.
Other Bankruptcies:
Have there been any other bankruptcies filed by someone other than you or your spouse
to stop a foreclosure on your home? YES _____ NO _____. If YES, give details:
4.
Occupation and Income:
A.
Usual type of work:
B.
Name and address of current employer:
C.
Spouse’s usual type of work:
D.
Name and address of spouse’s current employer:
E.
How long have you been at your current job?
Your spouse?
F.
List all income received in the last six months by you and your spouse (do not list your spouse’s income if you are
not filing bankruptcy together and you are legally separated):
(Bring a copy with you to our office of all pay stubs or other records from your employer of all pay received within the
past sixty days.)
Source
(Names and addresses of
employers or specify social security,
Income Received
By Whom
welfare, unemployment, child support,
(Give gross income)
self-employment, investments, etc.)
(Self or Spouse)
1 month ago:
2 months ago:
3 months ago:
4 months ago:
5 months ago:
6 months ago:

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