BANKRUPTCY INFORMATION FORM Important information, please take note: This form submitted by email and has the same degree of security as regular email. Consequently it is better not disclose and credit card or critical private information. The form is used to get your case started only. Do not fill this form unless you reside in PA or NJ. Filling out this form does not file a bankruptcy case! This information does not go to the court and does not afford you legal relief. Submission of this form does not mean that you have been accepted as a client, or that an attorney-client releationship has been established. You may become our client in only one way: you must sign a retainer agreement that is accepted by us. This sheet does not include room for a list of creditors and account numbers. For security reasons, these should be mailed or faxed to us. For address and phone numbers, see the contacts page.
Name on birth certificate:			MM/DD/YYYY:
E-Mail Address:			Spouse email:
Names used in past 6 years:			Maiden name if used w/in 6 yrs:
Have you filed a bankruptcy within the last 6 years?	No Yes		Yes No
If so, when?	MM/DD/YYYY:		MM/DD/YYYY:
Where?	Select State Not Applicable ------------------------- Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming		Select State/Province Not Applicable ------------------------- Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming ------------------------- Alberta British Columbia Manitoba New Brunswick Newfoundland Nova Scotia Northwest Territory Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon
Case number:
Street Address:			Spouse:
City, State, Zip code:			Spouse:
Do you own or rent your home?	Select option Own (subject to mortgage) Own free and clear Rent from landlord Live with parent/relative
Employer:			Spouse:
Employers address:			Spouse:
City, State, Zip code:			Spouse:
Home phone:			Spouse:
Pager:			Spouse:
Cell phone:			Spouse:
Work phone:			Spouse:
How long at current job?:			Spouse:
Previous employer: (if less than one year)			Spouse:
Social Security Number:			Spouse:
In this box, please list all dependents and whether they are living with you:
Wages you owe your employees, if any:			Spouse:
Taxes owing
To the United States:			Spouse:
To any state:			Spouse:
To any other taxing authority:			Spouse:
How did you get into financial difficulties?
Assets (please insert your estimated values)
Land or House (indicate whether owned by husband, wife or joint):	address; owner (h/w/j)
Cash on Hand:
Bank Accounts (Do not list acct #'s. List type of acct., bank, balance and owner):			Bank, checking/savings, owner, approx. balance
Ordinary furniture and appliances			Spouse, if not joint:
In this space, please list any collectibles you may have (e.g. stamp, coin or card collections, other antiques) Indicate whether hus/wife/joint:	list type, owner.value
Wearing apparel:
Furs & jewelry:	list type, owner, value
Firearms, sports equipment, tools, toys, computers, etc.:	list type, owner.value
Automobiles:	year, maker, owner,value
Boats and accessories:
Livestock, pets:	only animals of value
Office equipment, supplies, and furnishings:	list type, owner.value
Machinery, fixtures, equipment and supplies used in the business:	list type, owner.value
Inventory:
Patents and copyrights:	list type, owner. value,year of filing
Government and Corp. bonds:
Other debts owing debtor (i.e. tax refunds, wages):	lst debtor name, whether collectable or not,amount owed to you
Claims or lawsuits you have against someone else:	list type of lawsuit, damages claimed and attorney
Interest in insurance policies:	list life-not auto/health
Annuities and retirement monies:
Stocks, bonds, interest in corps:
Interest in Partnerships:
Future interests or life estates for the benefit of the debtor:
Property transferred within one year of filing Bankruptcy:
Property of any kind not otherwise scheduled (including out of state):
Give Estimated Average Current Monthly Income of Debtor and Spouse
Gross pay before deductions:			Spouse:
List all deductions:	Withholding taxes:
other deductions		Type of deduction: wage attachment support wage attachment creditor voultary deduction health insurance other		Type of deduction: wage attachment support wage attachment creditor voultary deduction health insurance other
Net pay after taxes & deductions:			Spouse:
Other Income from business or profession, interest and dividends, real estate or personal property, Social Security, workman's compensation, retirement, alimony or child support:
If you anticipate receiving additional income on other than a monthly basis in the next six months (such as an increase in salary or inheritance) please describe it:
If you anticipate a substantial change in your income in the immediate future, please explain it:
Monthly Expenses
Home Expenses Rent or home loan payment:
Real estate taxes:
Home Maint.:
Utilities/Electricity:
Natural gas & oil:
Water:
Telephone:
Cable TV:
Other (specify):
Taxes (not deducted from wages or included in home loan payment or included in real estate taxes):
Alimony or child support payments (list name, age and relationship of beneficiaries - could include a mother or other dependent dependent):	$
Life Insurance:
Health Insurance:
Auto Insurance:
Homeowner's/renter's Insurance:
Other Insurance(specify):
Installment Payments - Auto:
Installment Payments - Other (furniture, TV):
Transportation - gas and maintenance or bus pass:
Education (including tuition and school books, & trips):
Food (do not underestimate!):
Meals Out:
Baby Food:
Clothing:
Uniform:
Medical and Dental:
Laundry:
Child Care:
Diapers:
Newspapers, Magazines and books:
Recreation:
Charitable Contributions:
Other Expenses (Specify - Could include cigarettes, attorney's fees, accountants fees, travel costs, costs for child visitation, parking fees, etc.:
If you anticipate any major changes in your expenses in the immediate future, describe them:
1. Where else have you resided in the last two years:
2. Have you been in a partnership with anyone, or engaged in any business during the last six years:	yes no
3. What income did you receive from your job last year:
The year before that:
Two years previously:
4. What amount of income did you receive from other sources last year:
The year before that:
Two years previously:
5. What tax refunds did you receive last year:
The year before that:
Two years previously:
What refunds are you expecting this year?
6. Do you have records related to your financing:	yes no
7. What property do you hold for any other person?
8. What valuables are other persons holding for you?
9. Is any of your property in control of a receiver, trustee or other liquidating agent:	yes no
10. Have you given any of your property to creditors in the last year:	yes no
11. Is anybody suing you:	yes no
Do you have any lawsuits:	yes no
Have you been in any lawsuits in the last year:	yes no
Has any of your property or pay been attached, garnished or seized within the last year:	yes no
12. Have you made payments over $600 during the last year on debt:	yes no
13. Have you made any gifts or transfers of property over $200 to family members or charitable donations during the past year:	yes no
14. Has any of your property been repossessed during the past year:	yes no
15. Have you suffered any losses from fire, theft, ir gambling during the past year:	yes no
16. Have you consulted an attorney other than Dawn Smith during the past year:	yes no
17. Do you have a safe deposit box:	yes no
18. Have you closed any bank accounts during the past year:	yes no
Finally, do you have any other comments to add to this statement?