Chapter 7 Prepetition Agreement

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Step 1 of 14 - Personal Information

In order to prepare your petition, please complete the following Questionnaire and provide ALL of the applicable documents listed in the Document Checklist. Upon receipt, your paralegal will schedule an intake interview with you to prepare your petition. Please be absolutely candid and provide as much information as possible; too much information is better than too little. As your Attorneys, we ask that you be open and candid, so that we can give you the best advice possible. If you withhold information from us because you are embarrassed or don’t want to disclose all of your assets and/or debts, we cannot effectively represent you. Further, it is a crime if you don’t list all your assets and debts. It’s simply not worth the jail time to withhold information. In addition, providing false information is grounds for us to withdraw from your case. We will take every measure to ensure that your information is strictly confidential and protected by the attorney- client privilege and the attorney work-product privilege. The information and documents will be used for the sole purpose of drafting your Petition, Statements, Schedules, and related documents. PLEASE ANSWER ALL QUESTIONS: IF NOT APPLICABLE, PUT N/A. DO NOT LEAVE QUESTIONS UNANSWERED. It is critical that you list ALL of you creditors. TO ENSURE THAT ALL YOUR CREDITORS ARE LISTED, OBTAIN A FREE COPY OF YOUR CREDIT REPORT If you move, you must provide our office and the Trustee with the updated contact information. Some bankruptcies can last years. As a result, your attorney must always be able to contact you, especially in case of a deadline. Because people sometimes forget to update contact information, we ask that you provide us with long-term contact information. These people will only be contacted if we cannot locate you directly. These people will not be told the nature or purpose for the contact.
Instructions Reviewed: By checking the box below you certify that you have read and understand the above instructions regarding the completion of this Questionnaire.*
- Yes

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Personal Information
Full Name*
First Middle Last

AKA

List all of the names in addition to the name above you have used to obtain credit.

Phone*
Email*
Social Security Number*
Date of Birth*
MM slash DD slash YYYY
Full Address*
Street Address Address Line 2 City State ZIP Code
Mailing Address
Street Address Address Line 2 City State ZIP Code
Marital Status*
Prior Bankruptcies*
Who is Filing?*

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Spouse Name*
First Middle Last

Spouse AKA*

List all of the names in addition to the name above you have used to obtain credit.

Spouse Phone*
Spouse Email*
Spouse Social Security Number*
Spouse Date of Birth*
MM slash DD slash YYYY
Spouse Address
Street Address Address Line 2 City State ZIP Code
Enter if different

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Household Information
Do You have financial dependants living with you?*
Number in Household (You and all dependents)*
Please enter a number from 1 to 30.

Dependants Living With You*

Name	Age	Relationship

Do you have a domestic support obligation*
Select yes if one or more of the debtors who will be filing has a legal obligation to pay child support or alimony.

DSO Payments*

Name	Address	Monthly Amount	Arrears

List all people to whom a domestic support obligation is due (child support or alimony).

Do You Owe Taxes?

Hidden

Taxes*

IRS	State	Other

Case Issues
Have Your Wages Been Garnished in the Past 3 months?*
- Yes
- No

Garnishing Creditor*

Creditor Name	Creditor Address	Creditor Fax	Creditor Email	Amount

Enter the information regarding the creditor who is garnishing your wages.

Garnished Employer*

HR Contact Name	HR Address	HR Fax	HR Email

Enter the information regarding your employer whose wages have been garnished.

Do You Have a Foreclosure Sale Pending?*
- Yes
- No
Scheduled Foreclosure Date*
MM slash DD slash YYYY

Foreclosure Creditor*

Creditor Name	Creditor Address	Creditor Fax	Creditor Email	Amount

Enter the information regarding the creditor who is threatening Foreclosure.

Is a Creditor Threatening Repossession?*
- Yes
- No

Repossession Creditor*

Creditor Name	Creditor Address	Creditor Fax	Creditor Email

Enter the information regarding the creditor who is threatening Repossession.

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Please enter ALL of your property and its approximate value. The value should be the lowest reasonable value like the yard-sale value. A response is required for each question. If you do not have property in the group, enter "none" and "0" for the value.
Real Estate

Real Estate, Residence, Building, Land, Timeshares*

Location	Value	Amount Owed $

Mortgage Loans*

Description	Lender	Monthly Payment	Interest Rate	Keep/Surrender	Amount Past Due

Automobiles, Boats, Motorcycles, SUVs, Tractors

Automobiles/Boats/Motorcycles*

Year	Make	Model	Trim	Mileage	VIN	Value $	Amount Owed $

Auto Loans*

Description	Lender	Monthly Payment	Interest Rate	Keep/Surrender	Amount Past Due

Watercraft/Aircraft/Recreational/Other Vehicles*

Year	Make	Model	Value $	Amount Owed $

Personal Property

Large Kitchen Appliances (Fridge, Microwave, Freezer, Stove, etc.)*

Description	Quantity	Yard-sale Value

Washer, dryer, fridge, freezer, stove, microwave, sewing machines.

Carpets*

Quantity	Yard-sale Value	Notes

All carpets in use

Beds & Bedding*

Quantity	Yard-sale Value

Provisions*

Quantity	Yard-sale Value	Notes

Stock of food and necessary supplies for 1 year

Dining & Kitchen Tables & Chairs*

Quantity	Yard-sale Value	Notes

Sofas/Chairs & Related Furniture*

Quantity	Yard-sale Value

Enter dressers, couches and chairs, shelves, coffee table, end tables, lamps, household tools, desks kitchenware

Bedroom Furniture (other than beds & Bedding)*

Description	Quantity	Yard-sale Value

Dressers*

Quantity	Yard-sale Value

End-tables, Entertainment centers, Hutches, Coffee tables*

Description	Quantity	Yard-sale Value

Lamps, Mirrors, Vanity*

Description	Quantity	Yard-sale Value

Household Tools*

Description	Quantity	Yard-sale Value

Vacuum, hand tools, etc.

Desks*

Quantity	Yard-sale Value

Kitchen Appliances, Cookware, Dishes, & Utencils*

Description	Quantity	Yard-sale Value

Game Tables (Pool, ping pong, etc.)*

Description	Quantity	Yard-sale Value

Yard Accesories (BBQ, fire pit, heaters)*

Description	Quantity	Yard-sale Value

Yard Tools & Equipment (lawmower, hoes, rakes, shovels, etc.)*

Description	Quantity	Yard-sale Value

Electronics (Televisions, Stereo, DVD Players, Computer, Printer, etc)*

Description	Quantity	Yard-sale Value

Books, Music, Instruments, Pictures, Artwork, Stamp Collections*

Description	Quantity	Yard-sale Value

Recreational Equipment (bikes, skis, etc.)*

Description	Quantity	Yard-sale Value

Firearms & Ammunition*

Description	Quantity	Yard-sale Value

Wearing Apparel (clothing)*

Description	Quantity	Yard-sale Value

Jewelry*

Description	Quantity	Yard-sale Value

Miscellaneous Items*

Description	Quantity	Yard-sale Value

Checking, Savings, Cash & Cash Accounts*

Account Type (Checking, Savings, Pre-paid, etc.)	Institution	Account #	Amount

Stocks/Bonds/CD/Money Market*

Account Type	Institution	Amount

Education Savings Plans or State Tuition Plans*

Account Type	Institution	Owner	Present Value

Retirement Accounts*

Account Type	Institution	Amount

401(k), IRA, Pension or other

Life Insurance Policies*

Policy Type	Institution	Beneficiary	Cash Value

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Business Information
Do You or Your Spouse Have A Business?*
- Yes
- No
Business Name*
Entity Type*
Business Address*
Street Address Address Line 2 City State ZIP Code

Business Owners*

Owner	% Ownership

Date You Began The Business*
MM slash DD slash YYYY
Do you have the right to sue anyone for money?*
- Yes
- No
Do You Have any Current Contracts or Leases?*
- Yes
- No

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Executory Contracts

Contracts & Leases*

Description	Name	Address	Keep or

Executory Contracts include real estate leases, cell phone contracts and other periodic leases.

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Income
Employment Status*
Employer*

Income*

Self/Spouse	Employer	Gross Monthly Amount

Employer Address*
Street Address Address Line 2 City State ZIP Code
Pay Frequency*
How long have you worked here?*

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Spouse's Income Information
Spouse Employment Status*
Spouse Employer*
Spouse Employer Address*
Street Address Address Line 2 City State ZIP Code
How long has your spouse worked here?*

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Monthly Budget
This section deals with your household monthly budget. Please indicate the total amount for each monthly expense. If the monthly amount varies, please use an average over the past 6 months.
Rent or Mortgage Expense*
Property, homeowner or renter insurance*
Real Estate Taxes*
Home maintenance, repairs & upkeep*
HOA Dues or Condo Fees*
Additional mortgage or home equity loan payment*
Utilities - Electricity, heat, & natural gas*
Water, Sewer, & garbage*
Telephone, cell phones, cable, satellite & internet*
Other Utilites*
Food & Housekeeping Supplies*
Childcare & children's educatin costs*
Clothing*
Laundry/Dry Cleaning*
Personal Care Products & Services*
Medical & Dental Expenses*
Transportation (fuel, bus, train, but not auto loans)*
Entertainment, Clubs, Recreation, & Newspapers*
Charitable Contributions & Religious Donations*
Life Insurance*
Health Insurance*
Vehicle Insurance*
Other Insurance*
Taxes (that are not deducted from your wages)*

Installment or Lease Payments

Description	Comments	Amount

Alimony, maintenance & Support (not deducted from pay)*
Other Support Payments*

Other Monthly Expenses

Description	Comments	Amount

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Prior Addresses for the past 3 years

Address	City	State	Zip

Prior Addresses

Address	City	State	Zip

List all address where you have lived in the last 3 years.

In the past 8 years, have you lived in Arizona, California, Idaho, Louisiana, Nevada, New Mexico, Puerto Rico, Washington, or Wisconsin?*
- Yes
- No

Other Income in Past 2 Years*

Year	Amount	Source	Recipient

List income received other than business or job received , even if not taxable, that you have received from alimony, child support, social security, unemployment, other public benefits, pensions, rental income, dividends, lawsuits, royalties, gambling or lottery winnings.

Payments To Creditors*

Creditor	Date(s) of Payment(s)	Total Paid

List the total of all payments to each creditor that totals $600 or more in the past 90 days.

Payments to Insiders in Past 1 Year*

Creditor	Date(s) of Payment(s)	Total Amount

Insiders include your relatives, any general partners, or relatives of any general partners,

Payment or Transfers within 1 Year made that benefitted an Insider.*

See definition of insider above.

Lawsuits, court action, or administrative proceeding in past year.*

Case Caption	Case No.	Status

List all matters, including personal injuries, small claims, collection suits, paternity actions, divorce, child support, and contract disputes.

Property Repossessed, Foreclosed, Garnished, Attached, Seized or Levied within 1 year.*

Creditor	Property Taken	Property Value

Within 90 days set off of any amount from your account or refuse to make a payment because you owed a debt.*

Creditor	Description	Amount	Date

Property taken within 1 year in possession of an assignee for the benefit of creditors, court-appointed receiver, custodian, or another official.*

Creditor	Amount	Description

Gifts of $600 or more given to any person within past 2 years.*

Name	Relationship	Date(s)	Amount

Charitable Contributions of $600 or more*

Recipient	Description	Relationship	Date(s)	Total Amount

Property Losses within 1 Year caused by fire, theft, or other disaster, or gambling.*

Description of Property	Date of Loss	Value of Property

Payments for Bankruptcy*

Party	Date(s) of Transfer	Amount

List any payments you or someone else on your behalf has paid or transferred any property to anyone you consulted with about filing bankruptcy.

Payments for Dealing with Creditors*

Party	Date(s) of Transfer	Amount

List any payments you or someone else on your behalf has paid or transferred any property to anyone who promised to help you deal with creditors or to make payments to your creditors.

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Statements regarding your financial affairs.

List all property transfers, including property sold or trades to any person in the past 2 years.*

Party	Relationship	Date(s)	Value

List both outright transfers and transfers made as security to any person in the ordinary course of business. (Don't include any gifts or transfers already listed under another question.

Transfers to a self-settled trust in the past 10 years where you are a beneficiary.*

Trust Name	Date	Property	Value Received

Financial Accounts or Instruments that were closed, sold, moved, or transferred within past 1 Year.*

Institution	Type of Acount	Balance	Date of Closing

Include checking, savings, money market, or other financial accounts, certificates of deposit, shares in banks, credit unions, or other financial institutions.

Safe Deposit Box or other depository*

Institution	Parties with Access	Description	Value of Contents

Safe places to store securities, cash or other valuables.

Property In your Possession or Control that someone else owns.*

Owner	Description	Value of Property	Location

Include property you borrowed from, are storing for, or hold in trust for someone else.

Environmental Liability*

Location	Governmental Unit	Date of Notice	Environmental Law

List property that you have been notified by a governmental unit that you may be liable or potentially liable under or in violation of an environmental law.

Release of Hazardous Material*

Location	Governmental Unit	Date of Notice	Environmental Law

List all instances where you have notified a governmental unit of a release of hazardous material (hazardous waste, substance, toxic substance, pollutant, or contaminant or similar term under environmental law.

Judicial or Administrative Proceedings in which you were a party under any environmental law.*

Case Name	Case Number	Status

Businesses you have owned in the past 4 years.*

Business	Business Type	Nature of Business	Start Date	End Date

Business Financial Statements Provided in past 2 years.*

Institution	Date

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Chapter 7 Prepetition Agreement

Step 1 of 14 - Personal Information

Personal Information

Household Information

Case Issues

Real Estate

Automobiles, Boats, Motorcycles, SUVs, Tractors

Personal Property

Business Information

Executory Contracts

Income

Spouse's Income Information

Monthly Budget

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