Bankruptcy Questionnaire Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.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 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodePrior 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 *SingleMarriedDomestic PartnershipSeparatedDivorcedIf married, will this be a joint filing? (If NO, skip to dependents) *YesNoSpouse NameFirstLastHome Phone or Primary PhoneSocial Security NumberCurrent AddressAddress Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeDependents (if none, skip to next section) Dependent 1 - Name and AddressDependent 2 - Name and AddressDependent 3 - Name and Address Dependent 1 Date of BirthDependent 1 RelationshipDependent 1 Custody Percentage (if applicable)Dependent 2 Date of BirthDependent 2 Relationship Dependent 2 Custody Percentage (if applicable)Dependent 3 Date of BirthDependent 3 RelationshipDependent 3 Custody Percentage (if applicable)Do you have more than 3 dependents? *YesNoIf yes, enter how many more dependentsHave you or your spouse, jointly or otherwise, filed for bankruptcy before? *YesNoIf yes, provide case numberType of bankruptcyDate Petition was FiledDate Petition was FinalizedIf 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 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeLength 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 *$Account # / DescriptionVehicle Payments Partner A *$Partner B *$Jointly Owed *$Account # / DescriptionCar Insurance Partner A *$Partner B *$Jointly Owed *$Account # / Description Car Maintenance Partner A *$Partner B *$Jointly Owed *$Account # / DescriptionGasoline Partner A *$Partner B *$Jointly Owed *$Account # / DescriptionHealth Insurance Partner A *$Partner B *$Jointly Owed *$Account # / Description Medical / Dental Expense Partner A *$Partner B *$Jointly Owed *$Account # / DescriptionChildcare Partner A *$Partner B *$Jointly Owed *$Account # / DescriptionGroceries Partner A *$Partner B *$Jointly Owed *$Account # / DescriptionPhone / Internet Partner A *$Partner B *$Jointly Owed *$Account # / DescriptionUtilities Partner A *$Partner B *$Jointly Owed *$Account # / DescriptionPet Food / Care Partner A *$Partner B *$Jointly Owed *$Account # / Description Travel / Vacation Partner A *$Partner B *$Jointly Owed *$Account # / Description Entertainment Partner A *$Partner B *$Jointly Owed *$Account # / DescriptionClothing / Grooming Partner A *$Partner B *$Jointly Owed *$Account # / Description Monthly Memberships Partner A *$Partner B *$Jointly Owed *$Account # / DescriptionLife 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 *$Account # / DescriptionHOA Association Fees Partner A *$Partner B *$Jointly Owed *$Account # / Description Student Loans Partner A *$Partner B *$Jointly Owed *$Account # / DescriptionRetirement Planning Partner A *$Partner B *$Jointly Owed *$Account # / DescriptionRainy Day Fund Partner A *$Partner B *$Jointly Owed *$Account # / Description Child / Spousal Support PAID BY YOU Partner A *$Partner B *$Jointly Owed *$Account # / DescriptionTOTAL 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. AddressAddress Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeFair Market Value $Amount Owed on Property $Length of OwnershipOthers With Interest in Property by ParentagePrincipal Residence?YesNoIs This a Rental PropertyYesNoMonthly Rent Collected $Real Estate #2 Include all properties over the past 4 years. AddressAddress Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeFair Market Value $Amount Owed on Property $Length of OwnershipOthers With Interest in Property by ParentagePrincipal Residence?YesNoIs This a Rental PropertyYesNoMonthly Rent Collected $Motor Vehicles List all motor vehicles you have an ownership interest in. Vehicle 1 Year / Make / ModelVehicle ID Number (VIN #)Condition & MileageFair Market Value if SoldFinanced?YesNoFinance CompanyAmount Owed / Payoff AmountMonthly PaymentNumber of Payments LeftVehicle 2 Year / Make / ModelVehicle ID Number (VIN #)Condition & MileageFair Market Value if Sold Financed?YesNoFinance CompanyAmount Owed / Payoff AmountMonthly PaymentNumber of Payments Left Vehicle 3 Year / Make / Model Vehicle ID Number (VIN #)Condition & MileageFair Market Value if SoldFinanced? YesNoFinance CompanyAmount Owed / Payoff Amount Monthly Payment Number of Payments Left Personal Property Enter all personal property you own and amounts due to you. Retirement Account / 401K Partner A *$Partner B *$Jointly Owned *$Account # / DescriptionDeposit 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 *$Account # / DescriptionFurniture Partner A *$Partner B *$Jointly Owned *$Account # / DescriptionAppliances Partner A *$Partner B *$Jointly Owned *$Account # / DescriptionJewelry Partner A *$Partner B *$Jointly Owned *$Account # / DescriptionArt Partner A *$Partner B *$Jointly Owned *$Account # / DescriptionCollections Partner A *$Partner B *$Jointly Owned *$Account # / DescriptionFamily Heirlooms Partner At *$Partner B *$Jointly Owned *$Account # / DescriptionChild / Spousal Support Owed to You Partner A *$Partner B *$Jointly Owned *$Account # / DescriptionCash on Hand Partner A *$Partner B *$Jointly Owned *$Account # / DescriptionNotes / Receivable Partner A *$Partner B *$Jointly Owned *$Account # / DescriptionLife Insurance Partner A *$Partner B *$Jointly Owned *$Account # / DescriptionRent / Leases to You Partner A *$Partner B *$Jointly Owned *$Account # / DescriptionThis section is about your LIABILITIES. Enter 0 for N/A. Name of Person with Liability *Type & Acct. # (credit card, bank loan, mortgage, student loans, etc.) *Amount *Date Incurred *Status *CurrentPre-CollectionsCollectionsCurrent LawsuitJudgmentName of Person with Liability *Type & Acct. # (credit card, bank loan, mortgage, student loans, etc.) *Amount *Date Incurred *Status *CurrentPre-CollectionsCollectionsCurrent LawsuitJudgmentName of Person with Liability *Type & Acct. # (credit card, bank loan, mortgage, student loans, etc.) *Amount *Date Incurred *Status *CurrentPre-CollectionsCollectionsCurrent LawsuitJudgmentName of Person with Liability *Type & Acct. # (credit card, bank loan, mortgage, student loans, etc.) *Amount *Date Incurred *Status *CurrentPre-CollectionsCollectionsCurrent LawsuitJudgmentName of Person with Liability *Type & Acct. # (credit card, bank loan, mortgage, student loans, etc.) *Amount *Date Incurred *Status *CurrentPre-CollectionsCollectionsCurrent LawsuitJudgmentName of Person with Liability *Type & Acct. # (credit card, bank loan, mortgage, student loans, etc.) *Amount *Date IncurredStatus *CurrentPre-CollectionsCollectionsCurrent LawsuitJudgmentName of Person with Liability *Type & Acct. # (credit card, bank loan, mortgage, student loans, etc.) *Amount *Date Incurred *Status *CurrentPre-CollectionsCollectionsCurrent LawsuitJudgmentName of Person with Liability *Type & Acct. # (credit card, bank loan, mortgage, student loans, etc.) *Amount *Date Incurred *Status *CurrentPre-CollectionsCollectionsCurrent LawsuitJudgmentName of Person with Liability *Type & Acct. # (credit card, bank loan, mortgage, student loans, etc.) *Amount *Date Incurred *Status *CurrentPre-CollectionsCollectionsCurrent LawsuitJudgmentName of Person with Liability *Type & Acct. # (credit card, bank loan, mortgage, student loans, etc.) *Amount *Date Incurred *Status *CurrentPre-CollectionsCollectionsCurrent LawsuitJudgmentDo you have additional liabilities to list? *YesNoEnter additional liabilities here with all required information.Miscellaneous List any money owed to you, that was not previously listed, and why they are owed to you (social security, disability, unemployment, spousal/child support, etc.)Are you currently or have you ever been involved in a civil lawsuit? If so, provide the case number, County and State of the suite, and what the result was.Are there any judgments against you that have not been marked as satisfied? If so, provide the case number, County and State where the judgment was entered.Provide any additional information about your finances which may be helpful and relevant to this matter.Submit Call Us 888-357-3197 Address 33 Robinhood DrEtters, PA, 17319-9321, US Send a Message Name Email Address Message Submit
