CHAPTER 13
DEBTOR'S STATEMENT UNDER PENALTY OF PERJURY
Please make sure that all information is accurate on the date you appear for your 341 meeting. Debtor #1
Debtor #2 or Non-Filing Spouse
Name:______________________________________________ Name:______________________________________________ Address:___________________________________________ Address:___________________________________________ Primary Employer: _________________________________________
Primary Employer: _________________________________________
Employer Employer Address:___________________________________________ Address:___________________________________________ How long at this job: ____________________________ Are you paid hourly, salary or in some other way? (check one)
How long at this job: ____________________________ Are you paid hourly, salary or in some other way? (check one)
◘ Hourly: __________________ $________________
◘ Hourly: __________________ $________________
Hours per week
hourly rate
Hours per week
hourly rate
◘ Salary : $ ________________________ ◘ Monthly ◘ Annual ◘ Salary : $ ________________________ ◘ Monthly ◘ Annual ◘ Other : $ ________________________ ◘ Monthly ◘ Annual ◘ Other : $ ________________________ ◘ Monthly ◘ Annual Explain: Explain: Additional Sources and Amounts of Income:
Additional Sources and Amounts of Income:
List changes in income during the 6 months prior to filing bankruptcy (eg: raises, unemployment, job change, layoff)
List changes in income during the 6 months prior to filing bankruptcy (eg: raises, unemployment, job change, layoff)
Marital Status: (check one)
◘ Married and living with spouse ______ years ◘ Single ◘ Divorced for _______ years
◘ Married and not living with spouse ◘ Widowed
Household: List information for all persons living in your home (not incl. self and spouse) : Age Relationship contribution to household expense
full or part time in home
_______ __________________________________
$__________________________
◘ F/T
◘ P/T
_______ __________________________________
$__________________________
◘ F/T
◘ P/T
_______ __________________________________
$__________________________
◘ F/T
◘ P/T
_______ __________________________________
$__________________________
◘ F/T
◘ P/T
_______ __________________________________
$__________________________
◘ F/T
◘ P/T
_______ __________________________________
$__________________________
◘ F/T
◘ P/T
_______ __________________________________
$__________________________
◘ F/T
◘ P/T
List the ages of all your children who do not live with you: (do not include self-supporting adult children) Court Ordered Support: Are you required by court or administrative order or statute to pay support?: ◘ Yes
◘ No
Number of persons for whom you pay support: _________________ Monthly Support amount $________________ Have you made all support payments due after filing your bankruptcy petition?: ◘ Yes ◘ No List the amount of back support owed when you filed the bankruptcy petition (if none, enter $0): $____________________ Name and address of the person(s) to whom you pay support:
Tax Returns: ◘ I have filed state and federal tax returns for each of the four years prior to filing my bankruptcy petition (check all boxes ◘ I failed to file tax returns for the following years: that apply) ◘ The last tax return I filed was for the ______ tax year and I provided a true copy of this return to the Trustee Tax Refunds: The last tax refund I received was $_________________ Month and year received: ______________________ I spent the refund on: REAL ESTATE: List the requested information for each parcel of real estate you now own, owned when you filed your petition or are purchasing. Include real estate in which you have only a part interest. Use another sheet if there are more than three parcels. Address
_________________________ _________________________ _________________________
Date of purchase
_________________________ _________________________ _________________________
Purchase price
$________________________ $________________________ $________________________
Lender
_________________________ _________________________ _________________________
Fair Market Value
$________________________ $________________________ $________________________ ◘ Home
Use
◘ Rental
◘ Other
◘ Home
◘ Rental
◘ Other
◘ Home
◘ Rental
◘ Other
_________________________ _________________________ _________________________ # of units
◘ Single Family ◘ Duplex ◘ _______
◘ Single Family ◘ Duplex ◘ _______
◘ Single Family ◘ Duplex ◘ _______
Rent received
$________________________ $________________________ $________________________
(if any)
Name and relationship of other owners
Please read the following questions carefully and provide all necessary information below: ◘ Yes
◘ No I have read the Bankruptcy Information Sheet provided by the United States Trustee.
◘ Yes
◘ No I read the petition, schedules, statements and related documents before I signed them and I am personally familiar with the information contained in the petition, schedules, statements and related documents.
◘ Yes
◘ No To the best of my knowledge, and except as stated below, the information in the schedules, statements and related documents is true and correct, all of my assets are identified on the schedules, all of my creditors are listed on the schedules and there are no errors or omissions in those documents.
◘ Yes
◘ No I do not have any claims or causes of action against anyone for breach of contract, personal injury, worker's compensation, or for any other reason, except for those listed below.
◘ Yes
◘ No I have never filed bankruptcy before in any court anywhere using the social security number I presented today, the social security number on my bankruptcy petition, or any other social security number.
◘ Yes
◘ No I have consulted with my bankruptcy attorney prior to today.
List any information required by the above questions:
I STATE UNDER PENALTY OF PERJURY THAT THE ABOVE INFORMATION IS TRUE AND CORRECT AS OF TODAY
_______ Date
_____________________________ Debtor
_______ Date
____________________________________ Debtor
