Helping people file for bankruptcy relief under the Bankruptcy Code.
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This page now serves as the packet-based reference version of the firm's questionnaire. For the best client experience, start with the guided intake app and return here only when you need the full packet view.

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A cleaner way to complete the packet

This page keeps the original questionnaire content, but organizes it into a calmer intake workspace with progress, section jumps, draft saving, and language selection.

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Follow the original questionnaire order with cleaner fields.

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Bankruptcy intake packet

Complete each section as best you can. Use the section links to move around, and write NONE when a question does not apply. For security, use only the last 4 digits of Social Security or tax ID numbers in this web preview.

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Page 1

Start with household and filing details

Original form note: Please fill in ALL blanks or write "NONE."

Your filing status

Marital and filing status
Own a house?
Living with someone?

Non-filing spouse details

I have a spouse who is not filing
My spouse has filed before
I will provide non-filing spouse income and debt info

This helps the office determine what income, debt, and property details must still be gathered for a non-filing spouse.

Your legal name

Spouse legal name

Your address and contact details

Spouse address and contact details

Have you or a filing spouse ever filed bankruptcy before?

No discharge in 13 filed within 4 years of 7. No 7 for 8 years after filing a prior 7. Prior bankruptcies may disqualify you from filing, so be honest.

Purpose of appointment
Did you bring money to hire us?
Do you face or plan to
Any planned changes?
Do you have, or have you had, any of the following
Have you filed state and federal tax returns for the last 4 years?
Are you entitled to tax refunds, inheritances, lawsuit money, claim money, or assets that could help pay debt?
Run a free credit report and use the information?
Page 2

Statement of financial affairs

Are you living with someone?
Do you share expenses?

1(A) Your income from employment

Amount source

2(A) Your income from all other sources

1(B) Spouse or live-with income from employment

Amount source

2(B) Spouse or live-with income from all other sources

Have you or your spouse done any of the following?
Made payments to one creditor totaling more than $600 within the last 90 days
Made payments on a business debt over $5,000 in the last 90 days
Made payments to relatives or co-signers in the last year
Been involved in lawsuits, divorces, complaints, or administrative proceedings
Had property attached, garnished, or seized by creditors in the last year
Had property repossessed, foreclosed on, or returned to creditors within the last 4 years
Assigned property for the benefit of creditors in the last 120 days
Had property in the hands of a custodian, receiver, or court-appointed official in the last year
Made gifts over $200 or charitable contributions over $100 within the last year
Had gambling, fire, theft, flood, or other losses in the last 2 years
Made payments to anyone for debt consolidation or bankruptcy in the last year
Transferred, sold, or gave away anything, either outright or as collateral, within the last 4 years
Transferred money or property into a self-settled trust or similar device in the last 10 years
Closed, sold, or transferred financial accounts within the last year
Owned or had access to any safe deposit box within the last year
Had a creditor take money or property against any debt or deposit within the last 90 days
Have property that is owned by someone else
Are now, or have been, on title to anyone else's real estate, account, car, or property in the last 10 years
Lived at a different address in the last 3 years
Lived in another state within the last 8 years
Had any kind of matter open with another attorney in the last 3 years
Have you been engaged in any business in the last 6 calendar years before this one?
Expect any increase or reduction in income in the next year?
Were you married during that time?
Page 3

Secured personal debts, tax debts, leases, support, and co-debtors

The original questionnaire asks for contracts on every secured debt and tax transcripts for the last 4 years that were required to be filed.

Secured personal property debts

Secured debt 1

Your intent

Secured debt 2

Your intent

Secured debt 3

Your intent

Estate or federal tax debt

Did you file tax returns for the last 4 years?
Any other creditors with accounts or items secured by lien?

Leases and land purchase contracts

Support obligations

Current?

Co-debtors

Does co-signer have accounts at creditor?
Does co-signer have accounts at creditor?

Life insurance

Page 4

Dependents, employers, and monthly expenses

Dependents

Your pay schedule
Spouse pay schedule
Are you behind on support?

Monthly expenses schedule J

Page 5

Cash, bank accounts, household goods, and assets

Do you have over $500 in cash anywhere besides bank accounts?
Do you have checking or savings accounts or a safe deposit box?
Do you have any interest in credit union, CD, money market, mutual funds, IRA, or other financial accounts?
Does a utility company or landlord have a security deposit from you?
Household goods and personal property in the home
Are all your household goods together worth over $4,000 in a house sale?
Do you have any of the following assets or rights to money?
CDs, DVDs, records, or tapes
Used clothing that could be sold
Collections or collectibles
Fur coat or any jewelry
Firearms, sporting, or photo equipment
Life insurance through work
Life insurance not through work
Life insurance you can borrow against
Annuities or settlement income
Education IRA or prepaid tuition plan
Retirement plans such as pension, 401(k), 403(b), or IRA
Stocks or ownership in a business
Interests in partnerships or joint ventures
Government, savings, or corporate bonds
Accounts receivable or money owed to you
Alimony, maintenance, support, or property settlement owed to you
Future interests or life estates in real or personal property
Beneficiary of a will, trust, or insurance policy
Expecting to receive an inheritance
Contingent or unliquidated claims for or against you
Tax refund you normally receive
Patents, copyrights, or other intellectual property
Business or franchise licenses
Customer lists and information
Boats, motors, trailers, campers, or similar items
Aircraft and accessories
Office equipment, furnishings, or supplies
Inventory or a product you sell
Machinery, fixtures, equipment, or supplies used in business
Animals or family pets
Crops growing or harvested
Farm equipment, supplies, chemicals, or feed
Paid anyone like a creditor or family member recently
Page 6

Vehicles

The paper questionnaire asks for detailed vehicle features, insurance, lienholder, title, and co-signer information for every vehicle in which you have title or any interest.

Vehicle 1

Vehicle type
Intent
Balloon payment?
Insurance coverage
Is it in a shop or wrecked?

Vehicle 2

Vehicle type
Intent
Balloon payment?
Insurance coverage
Is it in a shop or wrecked?
Page 7

Real estate

Do you own your home or have an ownership interest in any real estate?
What type(s)?
Use
Was deceased spouse on title?

Mortgage holders and balances owed

1 mortgage

Variable rate or ARM?
Balloon payment?

2 mortgage

Variable rate or ARM?
Balloon payment?

3rd mortgage or lienholder

Are your real estate taxes current?
Have the taxes been sold?
Any liens or judgments?
In a mortgage forbearance plan?
Lawsuit or judgment against you?
Signed a quit-claim deed or transferred interest in last 10 years?
Any properties only in spouse's name?
If spouse-only property exists, have you ever been on title?
Are you on title to real estate but not on the mortgage?
Do you own or have any ownership interest in any other real estate?
Page 8

Asset and honesty disclosure

You must answer all questions and give details to any yes answer.
Refinanced real estate in the last 2 years
Property in storage or a vehicle held by a shop
Debts you did not tell us about that you want to keep
Any injury or death caused by intoxicated driving
Any student loans
Obtained property or credit by lying or fraud
Any willful injury or damage to a person or property
Currently buying or selling real estate
Assets you could sell to pay your debts
Fraud, embezzlement, or misappropriation
Overpayment of unemployment or Social Security benefits
Any property you did not already tell us about
New loans, balance transfers, or cash advances in the last 4 months
Charged over $1,000 on any one creditor in the last 4 months
A vehicle that is paid in full and titled in your name or someone else's name
Have or expect to receive money that could help pay bills
Any interest in real estate of any kind, including timeshare, condo, or vacant lot
Expect inheritance from someone who died
Are on title to someone else's real estate
Received or expect severance, settlement, winnings, retirement funds, sale proceeds, refinance proceeds, or other funds
Have injury, mental, economic, probate, or other claims planned or pending
Paid back loans or gave money or property to family or friends in the last 10 years
Have property jointly with another person, transferred something in the last 10 years, or hold something in someone else's name
Entitled to inheritance, probate, or wrongful death share
Paid off recent debts or hidden property to protect yourself, friends, or family
Are hiding something or failed to list all debts, property, or financial information
Listed every item of property with the correct market value to the best of your knowledge
Fully disclosed all assets, rights to assets, and every debt you owe
Are court ordered to pay child support
Please read this carefully. Lying on these forms or on a federal bankruptcy petition can result in the firm withdrawing from representing you, disclosure to the U.S. Trustee, and possible criminal charges punishable by a jail term of up to 5 years.

Major areas of lying listed on the original form include not disclosing injury, back pay, EEOC or discrimination claims, future money, debts paid to protect family or friends, stashed money, unlisted debts, unlisted personal property or cash, wrong market values, and undisclosed tax refunds.

Until a bankruptcy is filed, everything you tell the office is confidential. Only after filing is this information disclosed.

Please read and sign below

I read the above and have made full disclosure on all forms I have or will fill out, listed all of my debts and all possible assets in this case. It is a federal crime to lie. All statements were answered truthfully and to the best of my ability and I sign under penalty of perjury.

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ReferenceOriginal scanned questionnaireOpen Preview

Use this only as a source reference. The web form above is the cleaner intake experience for clients.

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