Chapter 7 Bankruptcy Questionnaire

Arizona’s leader in legal document preparation since 1998

2017 Chapter 7 Bankruptcy Questionnaire

13817 North 19th Ave., Phoenix, AZ 85023-6105 602-896-9020 Off. 602-896-1411 Fax. [email protected] DiscountDivorceAZ.com Rev. 3 May 2017

Bankruptcy Questionniare © 2017 Page 1

Instructions How to complete this questionnaire 1. Please print legibly; staff must be able to read this document to accurately complete your documents. 2.

Should you need additional space please make extra copies of this questionnaire and attach additional pages as needed.

3.

Please do not send or bring us your creditor statements. We cannot read the statements for you.

4. Please make a list of all creditors that you owe. The list must contain the name of the company, complete mailing address and approximate payoff amount. – You may also complete this list on our website at: http://discountbankruptcyaz.com/bkCreditors_1.html (Atlernatively you can bring us a credit report with this information.) 5.

As you complete this questionnaire if you have questions please call our office we would be happy to help you.

Make an Office Appointment After completing the questionnaire and making or obtaining a list of creditors that you owe please contact the office for an appointment Office Phone: 602-896-9020

Fax: 602-896-1411

Monday thru Thursday

9:00 am –12:30pm 1:30pm – 5:00pm

and

Friday

9:00 am –12:30pm

Saturday and Sunday Closed Office location: 13817 North 19th Ave., Phoenix, AZ 85023-6105 (Northeast corner of Thunderbird Rd. & 19th Ave., Subway’s ® parking lot) What to Bring to Your Appointment When you meet with us please bring the following items. 1.

A completed questionnaire.

2.

A copy of any law suits you have been served with.

3.

A photo ID, such as a driver’s license or state issued ID.

4.

A list of creditors that you owe or a copy of your credit report.

5. Payment: $199. NO PERSONAL CHECKS will be accepted. Fees can also be paid prior to your appointment via our secure website link at https://discountbankruptcyaz.com/onlinepayment .6. If you own a business (are a shareholder/partner/are on the board of directors/etc), have made payments for credit counseling, filed prior bankruptcy, paid an attorney, or any other unusual situation please inform us at the time of your appointment. The Court Will Require the Following: After your bankruptcy documents have been prepared by us the court will require all of the following items at the time of the initial filing. 1.

Photo ID.

2.

Social Security Card.

3.

Two (2) months of pay stubs.

4. Money order for Court’s filing fee. Current filing fee is $335. The court does offer a waiver or deferral (payment) plan on this fee. The court makes all determination regarding eligablity in all cases. 5.

Credit Counseling Certificate.

The Court is located at 230 North First Avenue, 1st Floor, Phoenix, AZ (Van Buren & 1st Ave.) There is all day parking for $2.50 just North of Van Buren on 1st Ave. on the East side of 1st Ave Please keep this page as reference. For legal advice we recommend calling the Arizona Bar Assoc. Attorney Referral Service at 602-257-4434 or www.LawerFinders.org


How to Obtain a Credit Report If you do not know who all of your creditors are, we recommend bringing in a copy of your credit report. You may use whatever service you wish to obtain a credit report but we require that the following information be on the credit report: 1.

Name of each creditor;

2.

Address of each creditor; and

3.

An approximate balance owed.

We recommend using Advantage Plus Credit Reporting, Inc., 7998 West Thunderbird Road, Ste. 109, Peoria, AZ 85381 Hours: Monday-Friday 8:00-5:00 MST Phone: 623-889-8999 Website: http://www.advpluscredit.com (Website is informational only. You cannot order your credit report from this site)

Email: [email protected] Advantage Plus Credit Reporting, Inc. charges $25 for a credit report without scores. Note: When ordering your credit report from Advantave Plus Credit Reporting, Inc. let them know that the credit report is for Discount Divorce & Bankruptcy and they will give you the proper report. ---------------------------------Note: We DO NOT RECOMMEND freecreditreport.com or creditkarma.com due to feedback we have received from past clients that have found that these credit reports do not give a complete and accurate picture of their credit history. ---------------------------------You may also order your credit report from: transunion.com  experian.com  equifax.com Alternatively you can complete this form on our internet site at: http://discountbankruptcyaz.com/bkCreditors_1.html Please keep this page as reference.


Chapter 7 Bankruptcy-Personal / Non-Business for 2017 Bankruptcy Filings

An Arizona Legal Document Company

Discount Divorce & Bankruptcy PO Box 83463 Phoenix, AZ 85071-3463 602-896-9020 Office 602-896-1411 Fax [email protected]

Part 1 Name

Personal Information

Address

First

Middle

Last

Street

City

State

Date of Birth (MM/DD/YYYY)

ZIP

Social Security No.

Email

Cell Phone

Spouse’s information if filing jointly Name Address

First

Middle

Last

Street

City

State

Date of Birth (MM/DD/YYYY)

Email

Social Security No.

Cell Phone


ZIP

Part 2

Elilgabitity

Income Test

What has been your average gross monthly income for the past six months from all income sources? (wages, child support, alimony, EBT, retirement benefits, unemployment benefits, etc.) DO NOT include Social Security

$

If filing jointly, what has been your spouse’s gross average monthly income for the past six months from all income sources?

$

per month

per month How many dependents do you support? Do all of these dependents reside with you?

Marital Status (Check only one)

Prior Filing and Consulting

If yes,

are any of these dependents eighteen years of age or older?

If yes,

do you claim all these dependents on your taxes?

 Yes No  Yes No  Yes No

Unmarried (Single) Married not filing jointly and declaring you and your spouse are not living together Married not filing jointly and you and your spouse are living together Married filing jointly Have you filed for a Chapter 7 bankruptcy in the past 8 years? Have resided in Arizona for the past 180 days Have you consulted with an attorney regarding bankruptcy?

 Yes No  Yes No  Yes No

Office Use Only Wages

$

Interest Dividends Unemployment

$

Revenue for Business Pension / Retirement Other

$

$

Rent

$

$

Support

$

$

Other 

Line 11 Column A

$

Line 11 Column B

$

Total Line 12

$

Line 12b (Line 12 x 12)

$

  1 Earner $46,779 2 People $58,684 3 People $62,227 4 People $72,052 5 People $80,452 6 People $88,852 7 People $97,252 8 People $105,652 Means Test Line 14B: as of 04/01/2017

Line 13 Number of people in the household and Med. Income Test

(add $8400 for each additional)


Part 3 1.

Assets Do you own any real estate? Who is the mortgage company? _______________________________________

 Yes No

Office Use 1.1 / 150,000 1101 Co-Debtor

Mortgage company’s address: _________________________________________

 Yes No

Mortgage company’s city, state and ZIP: _________________________________ What is the payoff on the mortgage? $_________________________ What is your montly payment amount $________________________ What do you want to do with your real estate?



Keep



Surrender

Where is your property located? Address: _________________________________________ City, State and ZIP: _________________________________ What is the fair market value? $________________________ Do you own any more real property?  Yes No

2.

Are you on a lease for an apartment, home, or other real estate? Who is your landlord? __________________________________

 Yes No

Landlord’s address: __________________________________________ Landlord’s city, state and ZIP: __________________________________ 3a.

Do you own or lease any cars, vans, trucks, tractors, sport utility vehicles, motorcycles?

 Yes No

Office Use 3.1 / 6000 1125(8)

Who is the lender company? _________________________________________ Co-Debtor

Lender company’s address: __________________________________________ Lender company’s city, state and ZIP: __________________________________ What is the payoff on the loan? $_________________________ What is your montly payment amount $________________________ What do you want to do with your vehicle?



Keep



Surrender

Describe your vehicle: Make: ____________________ Model: _____________________ Year: _____________________ Mileage: ____________________ What is the fair market value of the motor vehicle? $__________________


 Yes No

Part 3 3b.

Assets (Continued) Do you own or lease any other cars, vans, trucks, tractors, sport utility vehicles, motorcycles?

 Yes No

Office Use 3.1 / 6000 1125(8)

Who is the lender company? _________________________________________

Co-Debtor

Lender company’s address: __________________________________________

 Yes No

Lender company’s city, state and ZIP: __________________________________ What is the payoff on the loan? $_________________________ What is your montly payment amount $____________________ What do you want to do with your vehicle?



Keep



Surrender

Describe your vehicle: Make: ____________________ Model: _____________________ Year: _____________________ Mileage: ____________________ What is the fair market value of the motor vehicle? $____________ Do you own or lease any more motor vehicles?  Yes No 4.

Do you own or lease any watercraft, aircraft, motor homes, ATVs and other recreational vehicles, other vehicles, and accessories?

 Yes No

Co-Debtor

 Yes No

Office Use 6 / 6000 1123

Who is the lender company? _________________________________________

 Yes No

Lender company’s address: __________________________________________ Lender company’s city, state and ZIP: __________________________________ What is the payoff on the loan? $_________________________ What is your montly payment amount $____________________ What do you want to do with your vehicle?



Keep



Surrender

Describe your vehicle: Make: ____________________ Model: _____________________ Year: _____________________ Mileage: ____________________ What is the fair market value of this vehicle? $_________________ Do you own or lease any more vehicles?  Yes No 5.

Do you own any major appliances, furniture, linens, china, kitchenware? What is the fair market value of these items? $_____________________


Part 3 6.

Assets (Continued) Do you own any televisions and radios; audio, video, stereo, and digital equipment; computers, printers, scanners; music collections; electronic devices including cell phones, cameras, media players, games?

 Yes No

Office Use 7 / 6000 1123

 Yes No

Office Use 8 / None

 Yes No

Office Use 9 / 400 1125(2)

 Yes No

Office Use 10 / 1000 1125(7)

 Yes No

Office Use 11/ 1125(1) 500

 Yes No

Office Use 12 1125(4) /2000 1125(6) /150 watch

 Yes No

Office Use 13 / 500 1125(3)

 Yes No

Office Use 17.1 / 300 1126(A)(9)

 Yes No

Office Use 18 / None

What is the fair market value of these items? $_____________________

7.

Do you own any antiques and figurines; paintings, prints, or other artwork; books, pictures, or other art objects; stamp, coin, or baseball card collections; other collections, memorabilia, collectibles? What is the fair market value of these items? $_____________________

8.

Do you own any sports, photographic, exercise, and other hobby equipment; bicycles, pool tables, golf clubs, skis; canoes and kayaks; carpentry tools; musical instruments? What is the fair market value of these items? $_____________________

9.

Do you own any pistols, rifles, shotguns, ammunition, and related equipment? What is the fair market value of these items? $_____________________

10.

Clothes, furs, leather coats, designer wear, shoes, accessories. What is the fair market value of these items? $_____________________

11.

Do you own any jewelry, costume jewelry, engagement rings, wedding rings, heirloom jewelry, watches, gems, gold, silver? What is the fair market value of these items? $_____________________

12.

Do you own any dogs, cats, birds, horses? What is the fair market value of these items? $_____________________

13.

Do you have a checking, savings, or other financial accounts; certificates of deposit; shares in credit unions, brokerage houses, and other similar institutions? What is the fair market value of these accounts? $_____________________ Name of institution(s) your accounts are with?

14.

________________________

Do you have any bond funds, investment accounts with brokerage firms, money market accounts? What is the fair market value of these accounts? $_____________________ Name of issuer(s) your accounts are with?

________________________


Part 3 15.

Assets (Continued) Do you have an interests in IRA, ERISA, Keogh, 401(k), 403(b), thrift savings accounts, or other pension or profit-sharing plans?

 Yes No

Office Use 21 / 100% 38-792 AZ Retirement 33-1126(B) Other 33-1126(C) IRA 9-931 Police 9-968 Fire

 Yes No

Office Use 22 / 2000 33-1126(C) Residence only

 Yes No

Office use 26 / None

Type of account ____________________________ What is the fair market value of these accounts? $_____________________ Name of institution(s) your accounts are with? ________________________

16.

Do you have any unused deposits you have made so that you may continue service or use from a company? Examples: Agreements with landlords, prepaid rent, public utilities (electric, gas, water), telecommunications companies, or others Type of deposit ____________________________ (ie rent, gas, electric, etc.) Amount? $_____________________ Name of institution(s) or person (s) your deposit is with? __________________

17.

18.

Are currently expecting a tax refund?

State

Amount? $_____________________

Federal

Amount? $_____________________

other

Amount? $_____________________

Have you owned any interest in any business in the last four years? Name of the business? ________________________________________ Type of business:

 Sole proprietor  Limited liablity (LLC) or limited partnership (LP) Partnership  Officer, director or managing executive of a corporation Owner of at least 5% of the voting or equity securities of a corporation. Location of business: __________________________________________ City, state and ZIP of business: __________________________________ Type of business: _____________________________________________


 Yes No

Part 4

Co-Debtors 1.

Has anyone co-signed any loans for you in the past eight years?

 Yes No

What is that person’s name? _______________________________________ Person’s address: __________________________________________ Person’s city, state and ZIP: __________________________________ What is the name of the lender that the person co-signed for: ___________________________________________________________ Lender company’s address: __________________________________________ Lender company’s city, state and ZIP: __________________________________ Has this person co-signed for any other loans?  Yes No Are there anymore co-signors for anyother loans?  Yes No 2.

Within the last 8 years, were you married and did you live in a community property state or territory? (Community property states and territories include Arizona, California, Idaho, Louisiana, Nevada, New Mexico, Puerto Rico, Texas, Washington, and Wisconsin.) If this person is not filing jointly with you what is this person’s: Name? __________________________________________ Address: __________________________________________ City, state and ZIP: __________________________________



Person’s whereabouts are unknown to me.

Have you been married to anyone else in the past 8 years and did you live in a community property state or territory?

 Yes No


 Yes No

Part 5 1.

Income and Employment Are you employed?

 Yes No

Your occupation? ___________________________________________ Name of employer ? __________________________________________ Address of employer’s payroll dept.: _______________________________ City, state and ZIP: ____________________________________________ How long have you been employed there? _______ years. If filing jointly:

 Yes No

Is your spouse employed? Spouse’s occupation? ___________________________________________ Name of spouse’s employer ? __________________________________________ Address of spouse’s employer’s payroll dept.: ______________________________ City, state and ZIP: ___________________________________________________ How long has your spouse been employed there? _______ years. You

Spouse

$

$

$

$

List monthly gross wages, salary, and commissions 2. Estimate and list monthly overtime pay. 3. Total Income (Add line 2 and 3) 4. 5. 5a.

$

$

Payroll Deductions Tax, Medicare, and Social Security Deductions

$

$

5a.

Mandatory contributions for retirement plans

$

$

5b.

Voluntary contributions for retirement plans

$

$

5c.

Required repayments of retirement loans

$

$

5d.

Insurance …………………………………….

$

$

5e.

Domestic Support Obligations

$

$

5f.

Union Dues …………………………………..

$

$

5g.

Other Deductions ……………………………

$

$

5h.

Total Deductions Add lines 5a though 5h

$

$

Take Home Pay. Subtract Line 6 from Line 4

$

5b. 5c. 5d. 5e. 5f. 5g. 5h.

6.

7.


Part 5 8.

8a. 8b. 8c.

Income and Employment (Continued)

Net Income from rental property or from operating a business. Interest and dividends ……………………….

You

Spouse

$

$

8a.

$

$

8b.

Family support payments …………………… (alimony, child support, etc)

$

$

8c.

Unemployment compensations

$

$

8d.

Social Security ………………………………..

$

$

8e.

Other government assistance ………………

$

$

8f.

Pensions or retirement income ……………..

$

$

8g.

All other monthly income …………………….

$

$

8h.

9.

Total Other Income Add Lines 8a through 8h.

$

$

10a. and 10b.

Calculate montly income Add line 7 and 9

10a.$

10b.$

Total Add line 10a and 10b

$

8d. 8e. 8f. 8g. 8h.

State all other regular contributions to the expenses that you list.

11.

(ie. Include contributions from an unmarried partner, members of your household, your dependents, your roommates, and other friends or relatives.)

$

12.

Total Add line 10 and 11.

$

Do you expect an increase or decrease within the next year?

 Yes No


Enter this number in Part 6 Line 23a.

Part 6 1.

Expenses Is this a joint case?

 Yes No 2. 3.

If yes, does your spouse live in a separate household?

 Yes No Do you have dependants?  Yes No If yes, complete the information below for each child:

Son Daughter Son Daughter Son Daughter Son Daughter Son Daughter Son Daughter

Age

Does this child live with you?

Age


Age


Age


Age


Age


4. The rental or home ownership expenses for your residence. Include first mortgage payments and any rent for the ground or lot. 4a. Real estate taxes ………………………………………………………………………..

 Yes No  Yes No  Yes No  Yes No  Yes No  Yes No

4

$

4a

$

4b. Property, homeowner’s, or renter’s insurance ……………………………………….

4b

$

4c. Home maintenance, repair, and upkeep expenses ………………………………….

4c

$

4d. Homeowner’s association or condominium dues ……………………………………

4d

$

5.

Additional mortgage payments for your residence, such as home equity loans

5

$

6.

Utilities: 6a. Electricity, heat, natural gas ……………………………………………………………...

6a

$

6b. Water, sewer, garbage collection ………………………………………………………..

6b

$

6c. Telephone, cell phone, Internet, satellite, and cable services ………………………..

6c

$

6d. Other. Specify:

6d

$


Part 6

Expenses (Continued) Food and housekeeping supplies …………………………………………………………

7.

7

$

8.

Childcare and children’s education costs ………………………………………………..

8

$

9.

Clothing, laundry, and dry cleaning ………………………………………………………

9

$

10.

Personal care products and services …………………………………………………….

10

$

11.

11

$

12.

Medical and dental expenses …………………………………………………………….. Transportation. Include gas, maintenance, bus or train fare. …………………………. Do not include car payments.

12

$

13.

Entertainment, clubs, recreation, newspapers, magazines, and books ………………

13

$

14.

Charitable contributions and religious donations ………………………………………… Insurance. Not deducted from payroll 15a. Life insurance ………………………………………………………………………….

14

$

15a

$

15b. Health insurance ………………………………………………………………………

15b

$

15c. Vehicle insurance ……………………………………………………………………..

15c

$

15d. Other insurance. Specify: ……………………………………………………………

15d

$

16

$

17a

$

17b. Car payments for Vehicle 2 ………………………………………………………….

17b

$

17c. Other. Specify: ………………………………………………………………………..

17c

$

17d. Other. Specify: ………………………………………………………………………..

17d

$

18

$

19

$

20a. Mortgages on other property …………………………………………………………

20a

$

20b. Real estate taxes ………………………………………………………………………

20b

$

20c. Property, homeowner’s, or renter’s insurance ………………………………………

20c

$

20d. Maintenance, repair, and upkeep expenses ………………………………………..

20d

$

20e. Homeowner’s association or condominium dues …………………………………..

20e

$

15.

16. 17.

Taxes. Not deducted from payroll………………………………………………………………….. Installment or lease payments: 17a. Car payments for Vehicle 1 ………………………………………………………….

Your payments of alimony, maintenance, and support that you did not report as deducted in Part 5 18. 19.

Other payments you make to support others who do not live with you. Specify

20.

Other real property expenses not included in Part 5


Part 6 Expenses (Continued) Other expenses: 21.

21

$

22

$

23a. Copy line 12 from Part 5 (monthly income)

23a

$

23b. Copy your monthly expenses from line 22 above. ………………………………….

23b

$

23c. Subtract your monthly expenses, line 23b from your monthly income, line 23a The result is your monthly net income.

23c

$

22.

Calculate your monthly expenses. Add lines 4 through 21.

23.

Calculate your monthly net income.

Do you expect an increase or decrease in your expenses within the year after you file this form? 24. For example, do you expect to finish paying for your car loan within the year or do you expect your mortgage payment to increase or decrease because of a modification to the terms of your mortgage?

No  Yes, explain: If you and your spouse are not living together but are filing jointly copy and complete a separate Part 6 for them.


Part 7

Information Regarding Your Financial Affairs 1.

During the last three years, have you lived anywhere other than where you live now? Home no. 1

 Yes No

Address: __________________________________________ Office use 2

City, state and ZIP: __________________________________ Date you moved in: __________________________ Date you moved out: _________________________ Home no. 2 Address: __________________________________________ City, state and ZIP: __________________________________ Date you moved in: __________________________ Date you moved out: _________________________

2.

Did you receive any income from employment or the operation of a business during the last two calendar years and this current year? Your Income

If Filing Jointly Your Spouse’s Income

Income year to date

$_____________

Income year to date

$_____________

Last year’s income

$_____________


$_____________

Previous year’s income $_____________ 3.

 Yes No

Previous year’s income $_____________

Did you receive any income from any other source other than employment or the operation of a business during the last two calendar years and this current year? ie: Social Serurity, Retirement, Pension, Nutrional Assistance Program, Child Support, Alimoney, Unemployement Benefits.

Your Income

Office use 4

 Yes No

If Filing Jointly Your Spouse’s Income

Income year to date

$_____________

Income year to date

$_____________


$_____________


$_____________




Office use 5

Part 7

Information Regarding Your Financial Affairs (Continued) 4.

During the last 90 days have you paid any of your creditors $600 or more?

 Yes No

Lender’s name? ___________________________________________ Lender’s address: __________________________________________

Office use 6

Lender’s city, state and ZIP: __________________________________ How much was paid?

$ ______________________

How much is still owed? $ ______________________ What was this payment for? _____________________________________

5.

Within 1 year were you a party in any lawsuit, court action, or administrative proceeding? Please attach a copy of all lawsuits.

 Yes No Office use 9

How much are you being sued for $_________________________ 6.

Within 1 year was any of your property repossessed, foreclosed, garnished, attached, seized, or levied?

 Yes No

What was taken? ____________________________________ When was it taken? __________________________________

Office use 10

What was the market value of the item taken? $ ____________ Who was the creditor that took the item? ________________________________ 7.

Have you closed any financial accounts in the past year?

 Yes No

Name of financial institution? ________________________________________ Financial institution’s address: _______________________________________

Office use 20

Financial institution’s city, state and ZIP: _______________________________ What type of account:  Checking  Savings  Money Market  Brokerage  Other Last balance $ __________________ Date of closing _____________ Last four digits of account _______________

8.

Have you gone by any other name in the past 8 years? (maiden name, etc.) What was or is that name? __________________________________________


 Yes No

Part 8 A. Federal

Tax Debt Do you have any federal (IRS) tax debt?

No  Yes If yes, for what tax year(s) do you owe this debt for? ____________________ How much is owed? $___________________

B. State

Do you have any state tax debt?

No  Yes If yes, for what tax year(s) do you owe this debt for? ____________________ How much is owed? $___________________ What is their mailing address?

State Tax Authorty (agency’s) Name

Street address

City, State, and ZIP C. Other

Do you have any other government tax debt?

No  Yes If yes, for what tax year(s) do you owe this debt for? ____________________ How much is owed? $___________________ What is their mailing address?

State Tax Authorty (agency’s) Name

Street address

City, State, and ZIP


Part 9

Court’s Required Filing Fee 1.

How are you planning on paying the the court’s required filing fee of $335 at the time of filing of your Chapter 7 Bankruptcy? In Full Partrial

Part 10

Preferred Contact By Text: Yes No Many of our clients love to keep up to date on the status of their case. Would you like to receive text status updates to your cell phone regarding your case? Yes No If yes, who is your cell phone provider?

AT&T Verizon US Cellular Nextel

T-Mobile Boost

Sprint Alltel

Virgin Mobile Cricket

Other _______________ By Email: Yes No Part 11

By Phone: Yes No

Release We never release any information about you or your case to anyone other than the Court or 3rd parties that we contract to process your case (i.e. process servers, etc.) unless we are compelled by Court Order or with your permission. Is there anyone you want to authorize to call for information or pickup documents on your behalf?

No Yes If, yes who? Name: _____________________________________________________________ Relationship to you: _______________ Part 12

Signature and Disclosers

x



You certify that all the information contained herein is accurate to the best of your belief.



You acknowledge that purposely misleading the Court is a crime.



You acknowledge that Discount Divorce Pro., LLC is not a law firm and cannot provide legal advice.



You acknowledge that all fees are earned when paid and that there are no refunds or any partial refunds.



You acknowledge that it is your responsibility to proof read your legal documents once they have been prepared.



You acknowledge that there may be additional fees and court costs should you want to amened your documents once they have been produced or you have instructed us to begin preparation of your documents.

Date: dd/mm/yyyy


Chapter 7 Bankruptcy Questionnaire

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