Individual Bankruptcy Questionnaire

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Your Bankruptcy Questionnaire

Thank you for getting started! This questionnaire is divided in to 8 steps…

1) Personal Info

2) Assets

3) Debts

4) Wage Income

5) Self Employed Income

6) Other Income

7) Monthly Expenses

8) Misc.

Your attorney will use the information you provide to draft your bankruptcy petition, schedules, and statements. Prior to filing your case, you will review all of the documents with your attorney. If there are any last minute errors that need to be corrected or changes that need to be made, your attorney will do so prior to filing the documents.

At the end of the questionnaire you will be presented with the option to upload the required documents. If you have already provided these documents to your attorney or will email them separately, please disregard and finalize the questionnaire.

If you have any questions or problems with the questionnaire, please fee free to contact us at 954-484-9987 or send an email to info@fleysherlaw.com.

I. Personal Info

Current Address*Enter the address of your primary residence. Previous AddressIf you have been at your current residence for less than 3 years, please enter your prior address.Phone Number*Provide the best phone # for us to reach you. Your Email Address*

Your Date of Birth*

MM slash DD slash YYYY
Your Social Security Number*

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II. Assets

a.k.a. “Your Stuff”

Other Real EstateIf you own any other Real Estate (i.e., investment property, vacant land, vacation home, etc.) please list the address and brief description of each property.VehiclesPlease list the year, make, model, and approximate mileage for any cars, vans, trucks, motorcycles, ATVs, RVs, watercraft, or aircraft registered and/or titled in your name.

Additional Household Goods & FurnishingsIf you own any additional household goods or furnishings not listed above, please list the item(s) here and provide their approximate value(s)

Additional ElectronicsIf you own any additional electronics not listed above, please list the item(s) here and provide their approximate value(s)Your CollectiblesIf you own any collectibles of value (i.e., authenticated antiques, sports cards, sports memorabilia, rare stamps, rare coins, etc.) list the item(s) here along with the approximate value(s).Your Sporting or Hobby EquipmentIf you own any sporting or hobby Equipment (i.e., exercise equipment, bicycles, pool table, golf clubs, musical instruments, etc.) list the item(s) here along with the approximate value(s).Your FirearmsIf you own any firearms (i.e., pistols, rifles, shotguns, etc.) list the item(s) here along with the approximate value(s).Anything Else?If you own any other personal/household items you did not already list, including health aids, please list the item(s) here along with the approximate value(s).Bank AccountsPlease provide the account # and the name of the bank for each checking and/or savings account in your name. If the account is owned jointly with someone else, let us know that as well.Investment Accounts (Non-Retirement)Please provide the account # and the name of the institution for each non-retirement investment account in your name. These may include stock, stock accounts, mutual funds, bonds, etc. If the account is owned jointly with someone else, let us know that as well. Do not add your IRA or 401(k) accounts here.Undeposited FundsIf you are currently holding any checks, money orders, certified funds, etc. made payable to you please list the item(s) here along with the amount(s). This is common where a property insurance company has drafted a check payable to you, your contractor, and the mortgage bank.

Lawsuits or ClaimsIf you have any lawsuits or claims pending against someone else and you expect to receive money or other compensation as a result of the lawsuit(s) or claim(s) please briefly describe each lawsuit or claim in this space.
Common examples of such a lawsuit or claim would be a car accident where you were injured and not at fault; a property damage insurance claim for which you have not yet been paid; etc.

Anything Else?In the unlikely event you own or have an interest in any other asset not disclosed above, please describe the item(s) here along with the approximate value(s).
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III. Your Debts

Your attorney will obtain a tri-merge credit report which will provide a list of your consumer debts. The credit report will provide the names, addresses, account numbers, and balances of each consumer account reported in your name. The credit report typically shows all mortgages, car loans, credit cards, department store cards, and most debts being serviced by a collection company.

However, some debts are typically not reported to the credit bureaus (i.e., doctor bills, old utility bills, personal loans from private individuals, etc.). Prior to filing your case, your attorney will review the final list of creditors with you to make sure they are all properly listed and included.Your Non-Consumer DebtsPlease provide a list of your non-consumer debts (i.e., doctor bills, hospital bills, old utility bills, personal loans from private individuals, etc.). Be sure to include the name of the creditor, the creditor’s address, and the approximate amount owed.

Tax DebtIf you owe any taxing authority (i.e., IRS, State, County, or City) back taxes, please describe each debt below. Be sure to include the type of debt, the approximate amount, and the year the debt was incurred.

Some taxes may be dischargeable and your attorney will review the information and advise how your tax debt will be handled in your bankruptcy.
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IV. Wage & Employment

Your Current Employer Your Current Occupation Approximate Hire Date?The approximate month and year you began working for the above employer.
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V. Self-Employed Income

What’s your business?Please provide a brief description of your business or contracting work. Please include the name of the business ,the business address, the products or services provided, etc.Average monthly income from operation of your business(es)Please provide your net income and not your gross revenue.

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VI. Other Income

Non-Filing Spouse’s IncomeIf you are married and your spouse is not joining you in the bankruptcy filing, please provide her gross monthly income and whether he/she is a W2 employee receiving pay stubs or an independent contractor receiving a 1099. Even if your non-filing spouse is not filing for bankruptcy, we will still have to provide his/her pay stubs to prove the total household income to satisfy the bankruptcy court’s Means Test.Your average monthly income from Rental Property (if any) Your average monthly income from Child Support or Alimony (if any) Your average monthly income from Pension (if any) Your average monthly income from Social Security (if any) Your average “other” monthly income (if any)
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VII. Monthly Expenses

Rent or MortgageHow much do you pay per month for your Rent or Mortgage Payments. If you pay a mortgage, provide the Principal + Interest + Tax + Insurance (PITI) payment. If you have a 2nd mortgage (a.k.a. Home Equity Line of Credit) do not include that payment on this line.2nd Mortgage / Home Equity Loan / HELOCIf you have a 2nd Mortgage (a.k.a. Home Equity Loan, Home Equity Line of Credit, HELOC) please enter the regular scheduled monthly payment amount here.Condo/HOA DuesFPL/PowerWaterCell PhoneCable and/or InternetFood and Housekeeping SuppliesChildcare and Children’s Education CostsClothing, Laundry, and Dry CleaningPersonal Care Products and ServicesMedical and Dental ExpensesTransportationInclude gas, maintenance, bus or train fare. Do not include car payments.LeisureEntertainment, movies, clubs, recreation, newspapers, magazines, and books.Charitable Contributions and Religious DonationsCar InsuranceHealth Insurance (not deducted from paycheck)Car Payment(s)Monthly lease or finance payment(s)Installment PaymentsTax payment plans, financed vehicle or boat loans, mortgage payments for non-homestead property, etc.Child Support or Alimony (not deducted from your paycheck)
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VIII. Almost finished…

Just a few more miscellaneous questions to answer…

If yes, please list each payment (amount, recipient, and date) below.

If yes, please describe the settlement below.

If yes, please describe the Repossession, Foreclosure, or Garnishment below.

If yes, please describe the gift below.

If yes, please describe the losses below.

If yes, please describe the transfers below.

If yes, please describe each payoff or refinance below.Include the date(s) and whether you received any cash back at closing.

If yes, please provide the date of the divorce filing or date the Marital Settlement Agreement (MSA) was finalized.

If yes, please list each transferred or closed account below.Include the date the account was closed/transferred, the balance in the account when it was closed/transferred, and the name of the bank/financial institution.

If yes, please describe the contents of the safe deposit box below.

If yes, please describe the contents of the storage unit below.

If yes, please describe each ownership interest/connection below.

Congrats! You’ve reached the end of the questionnaire.

If you have not already submitted the required documents to your attorney, you may do so by uploading them below. You may also email the required documents to info@fleysherlaw.comTax ReturnsPlease provide your 2 most recent personal income tax returns. If you field a business tax return (1120 or 1120S) please provide those as well.
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Bank StatementsPlease provide the 6 most recent monthly bank statements for any accounts with your name on them.
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Pay StubsPlease provide all pay stubs received in the last 6 months.

If you are married, please provide your spouse’s pay stubs as well. Even if your spouse is not joining in on the bankruptcy filing with you, we still require his/her pay stubs to establish monthly household income. The non-filing spouse’s information will not otherwise be included in or attached to your bankruptcy filing.
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Automobile Registration or TitleIf you own any automobiles that are paid off, please upload the title here. If you can’t find the title, or if you have any automobiles registered to you that are leased or financed, please upload the registration(s) here.
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Automobile InsuranceIf you have any automobiles titled or registered in your name, please upload proof of insurance here. Our clients typically provide a copy of the wallet card they keep in their car near the registration.
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Misc.If you have any additional documents you would like to provide to your attorney (i.e., additional creditors, bills, statements, etc.) please upload them here.
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NameThis field is for validation purposes and should be left unchanged.
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