Upload your screenshot that indicates you ARE ELIGIBLE for bankruptcy.

Click or drag a file to this area to upload.

Full name, Maiden name and list of aliases:

Social Security Number

Birthday

Current Address

Address Line 1

Address Line 2

City

State

Zip Code

Prior addresses you have had over the last 5 years. If none other, enter N/A

Drivers License / State ID Number

Home Phone or Primary Phone

Email

Marital Status

If married, will this be a joint filing? (If NO, skip to dependents)

Yes
No

Spouse Name

First

Last

Home Phone or Primary Phone

Social Security Number

Current Address

Address Line 1

Address Line 2

City

State

Zip Code

Dependents (if none, skip to next section)

Dependent 1 – Name and Address

Dependent 2 – Name and Address

Dependent 3 – Name and Address

Dependent 1 Date of Birth

Dependent 1 Relationship

Dependent 1 Custody Percentage (if applicable)

Dependent 2 Date of Birth

Dependent 2 Relationship

Dependent 2 Custody Percentage (if applicable)

Dependent 3 Date of Birth

Dependent 3 Relationship

Dependent 3 Custody Percentage (if applicable)

Do you have more than 3 dependents?

Yes
No

If yes, enter how many more dependents

Have you or your spouse, jointly or otherwise, filed for bankruptcy before?

Yes
No

If yes, provide case number

Type of bankruptcy

Date Petition was Filed

Date Petition was Finalized

If bankruptcy was not finalized, why?

If represented by council, who?

Employer Name (If none, enter N/A)

Employer Phone (if none, enter N/A)

Employer Address is Required (if none, skip)

Address Line 1

Address Line 2

City

State

Zip Code

Length of employment (specify in months if less than 1 year). If none, enter N/A

Gross/Net annual income from Job (If none, enter N/A)

List other sources of income and annual income derived from them. (If none, enter N/A)

This section is about your EXPENSES. Enter 0 for N/A.

Anticipated change in earning capacity (promotion / retirement / layoffs, etc.)

Rent/Mortgage

Partner A

$

Partner B

$

Jointly Owed

$

Account # / Description

Vehicle Payments

Partner A

$

Partner B

$

Jointly Owed

$

Account # / Description

Car Insurance

Partner A

$

Partner B

$

Jointly Owed

$

Account # / Description

Car Maintenance

Partner A

$

Partner B

$

Jointly Owed

$

Account # / Description

Gasoline

Partner A

$

Partner B

$

Jointly Owed

$

Account # / Description

Health Insurance

Partner A

$

Partner B

$

Jointly Owed

$

Account # / Description

Medical / Dental Expense

Partner A

$

Partner B

$

Jointly Owed

$

Account # / Description

Childcare

Partner A

$

Partner B

$

Jointly Owed

$

Account # / Description

Groceries

Partner A

$

Partner B

$

Jointly Owed

$

Account # / Description

Phone / Internet

Partner A

$

Partner B

$

Jointly Owed

$

Account # / Description

Utilities

Partner A

$

Partner B

$

Jointly Owed

$

Account # / Description

Pet Food / Care

Partner A

$

Partner B

$

Jointly Owed

$

Account # / Description

Travel / Vacation

Partner A

$

Partner B

$

Jointly Owed

$

Account # / Description

Entertainment

Partner A

$

Partner B

$

Jointly Owed

$

Account # / Description

Clothing / Grooming

Partner A

$

Partner B

$

Jointly Owed

$

Account # / Description

Monthly Memberships

Partner A

$

Partner B

$

Jointly Owed

$

Account # / Description

Life Insurance

Partner A

$

Partner B

$

Jointly Owed

$

Account # / Description

Homeowners/Renters Insurance

Partner A

$

Partner B

$

Jointly Owed

$

Account # / Description

Home Maintenance

Partner A

$

Partner B

$

Jointly Owed

$

Account # / Description

HOA Association Fees

Partner A

$

Partner B

$

Jointly Owed

$

Account # / Description

Student Loans

Partner A

$

Partner B

$

Jointly Owed

$

Account # / Description

Retirement Planning

Partner A

$

Partner B

$

Jointly Owed

$

Account # / Description

Rainy Day Fund

Partner A

$

Partner B

$

Jointly Owed

$

Account # / Description

Child / Spousal Support PAID BY YOU

Partner A

$

Partner B

$

Jointly Owed

$

Account # / Description

TOTAL EXPENSES

Partner A TOTAL

$

Partner B TOTAL

$

Jointly Owed TOTAL

$

This section is about your ASSETS. Enter 0 for N/A.

You are required to disclose all assets.

Real Estate #1

Include all properties over the past 4 years.

Address

Address Line 1

Address Line 2

City

State

Zip Code

Fair Market Value $

Amount Owed on Property $

Length of Ownership

Others With Interest in Property by Parentage

Principal Residence?

Yes
No

Is This a Rental Property

Yes
No

Monthly Rent Collected $

Real Estate #2

Include all properties over the past 4 years.

Address

Address Line 1

Address Line 2

City

State

Zip Code

Fair Market Value $

Amount Owed on Property $

Length of Ownership

Others With Interest in Property by Parentage

Principal Residence?

Yes
No

Is This a Rental Property

Yes
No

Monthly Rent Collected $

Motor Vehicles

List all motor vehicles you have an ownership interest in.

Vehicle 1

Year / Make / Model

Vehicle ID Number (VIN #)

Condition & Mileage

Fair Market Value if Sold

Financed?

Yes
No

Vehicle 2

Year / Make / Model

Vehicle ID Number (VIN #)

Condition & Mileage

Fair Market Value if Sold

Financed?

Yes
No

Vehicle 3

Year / Make / Model

Vehicle ID Number (VIN #)

Condition & Mileage

Fair Market Value if Sold

Financed?

Yes
No

Personal Property

Enter all personal property you own and amounts due to you.

Retirement Account / 401K

Partner A

$

Partner B

$

Jointly Owned

$

Account # / Description

Deposit Account

Partner A

$

Partner B

$

Jointly Owned

$

Account # / Description

Stocks / Bonds / Securities

Partner A

$

Partner B

$

Jointly Owned

$

Account # / Description

Annuities

Partner A

$

Partner B

$

Jointly Owned

$

Account # / Description

Furniture

Partner A

$

Partner B

$

Jointly Owned

$

Account # / Description

Appliances

Partner A

$

Partner B

$

Jointly Owned

$

Account # / Description

Jewelry

Partner A

$

Partner B

$

Jointly Owned

$

Account # / Description

Art

Partner A

$

Partner B

$

Jointly Owned

$

Account # / Description

Collections

Partner A

$

Partner B

$

Jointly Owned

$

Account # / Description

Family Heirlooms

Partner At

$

Partner B

$

Jointly Owned

$

Account # / Description

Child / Spousal Support Owed to You

Partner A

$

Partner B

$

Jointly Owned

$

Account # / Description

Cash on Hand

Partner A

$

Partner B

$

Jointly Owned

$

Account # / Description

Notes / Receivable

Partner A

$

Partner B

$

Jointly Owned

$

Account # / Description

Life Insurance

Partner A

$

Partner B

$

Jointly Owned

$

Account # / Description

Rent / Leases to You

Partner A

$

Partner B

$

Jointly Owned

$

Account # / Description

This section is about your LIABILITIES. Enter 0 for N/A.

Name of Person with Liability