Client Bankruptcy Questionnaire Philip G. Jones, 853 West Center, Orem, Utah (801) Basic Instructions

Transcription

1 Client Bankruptcy Questionnaire Philip G. Jones, 853 West Center, Orem, Utah (801) Basic Instructions 1. It is important that you be as complete, accurate and truthful as possible in answering each of the questions on the attached questionnaire. If in doubt, put the information down and let the Attorney determine the legal significance of the information and whether it should be included on the final documents presented to the Court. 2. Please be aware that the information you provide is subject to audit verification by the Court. If you cannot verify as truthful the information in your bankruptcy papers or an audit discloses that you were not truthful, your case could be dismissed and you could be subject to civil and/or criminal sanctions. Under the new law random audits take place in every 50 to 250 cases. Copies of all documents used to prepare your questionnaire should be supplied to the attorney. 3. A person who knowingly and fraudulently conceals assets or makes a false oath or statement in connection with a case may be subject to fine, imprisonment, or both. 4. If you need more room to answer a question or provide supplemental explanations, feel free to attach separate sheets of paper. 5. If you are married, place the husband s information first on page 3 and the wife s information second. 6. If you are filing individually, but have a domestic partner, place your partner s information in spouse section on page 3 and cross out the word spouse. 7. If you are married, but filing individually, complete all of the sections of the questionnaire. Be sure to note carefully any separate assets that your spouse may own as well as any debts for which your spouse may be separately liable. 8. Be sure to read carefully and follow the instructions at the beginning of each section. 9. If you do not understand a question, or are unsure how you should answer, place a question mark in the margin and go on to the next question. If after having completed the rest of the form, you still have questions, please call the office and ask your questions. For a Chapter 7 ask for Alie. For a Chapter 13 ask for Laura. Alternately, you may make an appointment with the attorney. 10. Once you have completed the questionnaire to the best of your ability, you should make an appointment to go over the questionnaire with the attorney. Please do not drop off your questionnaire without having made an appointment to review it with the Attorney. There may be additional questions or important information that he must give you to protect you. Please also note that you are not in our system, are not our client, and no work will be performed for you; until you return the properly completed questionnaire, all of the applicable documents on the checklist, pay the retainer, and sign the Financial Agreement with the attorney. If creditors call before then they may be informed that you are not our client. 11. Be aware that the attorney cannot complete the filing of your bankruptcy without complete information. Your case also cannot be filed until you sign the finished documents and pay the sums indicated on page Please write legibly. If we cannot read your writing we cannot be responsible for errors on your pleadings. 13. If you leave off any debts, the court will require you to pay an additional filing fee before these can be added to your bankruptcy. 14. Please be aware that the attorney will only accept Chapter 7 Clients from Utah, Wasatch, Duchesne, Uintah, Juab, Sanpete, Carbon, Millard, Sevier, Emery, Grand and San Juan Counties. 16. When copies of documents are requested, do not give us your original documents. Provide us with photocopies. Please do not ask us to copy documents for you. We have converted to an electronic filing system and are no longer set up to make large numbers of copies. Page 1

2 Filing Information Do any of the following statements apply to you: I am on active duty in a military combat zone, I am impaired by reason of mental illness or mental deficiency so that I am incapable of realizing and making rational decisions with respect to my financial responsibilities, or I am so physically impaired as to be unable, after reasonable effort, to participate in an in a telephone or internet briefing that will take approximately 90 minutes to complete. If the answer was yes to any question, please enter the details below: If you need your case filed at a time other than a normal filing, please explain in the space below (a) the nature of the emergency, (b) the date, time, and location of the event you are concerned about, and (c) who needs to be contacted with your bankruptcy filing information. Please attach copies of any pertinent documents. If you do not have an emergency, but would like your case filed before or after a certain date, please let the attorney know by writing an explanation in the space below. If you are filing to stop a foreclosure or garnishment, please not all pertinent information including (if appropriate) the name and fax number of the individual responsible for handling garnishments in your payroll department. If you are a renter and your landlord has an order of eviction against you (or has requested one from the court), and you are still living in the property, please attach a copy of the order (or request) and indicate below why you are still in the property and when you intend to leave. During the last 5 years have you caused death or injury to any person? If yes, please explain. Do you have a domestic support obligation to a former spouse or partner, or any other person? If yes, describe: Do you own or have possession of any property that poses or is alleged to pose a threat of imminent and identifiable harm to public health or safety? If yes, describe: Page 2

3 Personal Information - Petition Name: Last First Middle Phone: Home Work Cell Have you used any other names in the past eight years? No Yes If Yes, list other names: Social Security Number (or TIN): - - Address Street Address: City: State: Zip: County: Have you lived at this address for at least 180 days? No Yes If you have a different mailing address, please list: Mailing Address: City: State: Zip: County: Name of Nearest Relative: Phone Street Address: City: State: Zip: County: Spouse/Partner Name: Last First Middle Spouse/Partner Phone: Home Work Cell Has your spouse/partner used any other names in the past eight years? No Yes If Yes, list other names: Social Security Number (or TIN): - - Address Street Address (if different from above): City: State: Zip: County: Have you lived at this address for at least 180 days? No Yes If you have a different mailing address, please list: Mailing Address (if different from above): City: State: Zip: County: Name of Nearest Relative: Phone Street Address: City: State: Zip: County: Do you wish to file a Chapter 7 or a Chapter 13? Is this a joint or individual filing? Has a bankruptcy case been filed by you or against you in the last 8 years? No Yes If yes, list all cases: Case # State of Filing Date Filed Chapter Completed? Attorney Is a bankruptcy case pending against you, a relative, or a business in which you have an interest? No Yes If yes Case # Debtor State of Filing Date Filed Chapter Relationship Judge Page 3

4 Real Property - Schedule A List below any interest you (or your spouse) may have (other than leases or rental agreements) in any land, home, buildings, time share units, vacation packages, mobile home, etc., even if you still owe money on the property. If you wish to keep the property you must continue to make your monthly payments after filing. Your Residence Type of Property: Address Owners (and % of ownership) Market Value Purchase Price Year of Purchase Want to keep home? No Yes Lender Total Amount in Default Loan Balance 1st 2 nd 3 rd Type of Property: Address Owners (and % of ownership) Market Value Purchase Price Year of Purchase Want to keep home? No Yes Lender Total Amount in Default Loan Balance 1st 2 nd 3 rd Type of Property: Address Owners (and % of ownership) Market Value Purchase Price Year of Purchase Want to keep home? No Yes Lender Total Amount in Default Loan Balance 1st 2 nd 3 rd Page 4

5 Personal Property - Schedule B List below any interest you (or your partner) may have (other than leases or rental agreements) in any property not listed on the previous page. Ownership: J for Joint (meaning anything you and your partner have acquired since you have been together). M for Male (meaning anything he brought into the relationship with him or that was gifted to him by someone other than a spouse or partner). F for Female (meaning anything she brought into the relationship with her or that was gifted to her by someone other than a spouse or partner). Titled Property: For any titled property (like a car, boat, or trailer) add the following designation in the ownership column as appropriate - TJ (titled in both your names), TM (titled in his name only, TF (titled in her name only), TJRM (titled jointly with a relative by him), TJRF (titled jointly with a relative by her). Property: If you have items that are not on the following list, attach separate sheets as necessary. If you make a separate list, it is still important to supply all of the information requested below. If you have more than one of a particular item, note how many you have in the description column. Value: The market value of an item is its resale, execution sale, or yard sale value. For vehicles enter the bluebook private party sale value or what you really think you could sell it for if there is no listing. If you have questions, ask the attorney. Place a * next to any item that is of particular importance or emotional value to you. Place an X in the value column on any items you do not have. Debt: In the debt column list the amount of any debt that may be pledged against this item. In other words, do you still owe money on it? If yes, list the amount. Ownership Description of Property Value Debt Financial Cash, in wallet, safety deposit box, etc. Bank Account, Q Checking Q Savings Q (name of institution) Bank Account, Q Checking Q Savings Q (name of institution) Bank Account, Q Checking Q Savings Q (name of institution) CD s (Certificates of Deposit) (name of institution) Security deposit held by landlord. (description) Security deposit held by utility companies or others. (description) Household Goods Beds (including mattresses) (how many) Misc. bedding and linens Microwave oven Range or Stove Refrigerator Freezer Washer Dryer Sewing machine Rugs & Carpets Couches (how many) Page 5

6 Love Seats Living room chairs (how many) Misc. tables (how many) Dressers (how many) Dishwasher Entertainment Center Dining table and chairs (# of chairs) Kitchen table and chairs (# of chairs) Dishes, pots, pans and silverware Kitchen appliances Food (including storage items) Bookshelves Desks Lamps Vacuum cleaner Misc. clothing (not including furs) Other household furnishings Electronics Normal television (how many) Big screen tv (home theater system, Q yes Q no Stereo Equipment VCR DVD Player Computer & Accessories Computer & Accessories Laptop Musical Instruments, Books, and Art Piano (what kind) Other Musical Instrument Musical Instrument Books Pictures of family or art created by family members (and not held for sale) Page 6

7 Collectibles (list separately) All other Art objects (if extensive attach a list) Misc. decorations (if valuable list separately) CD s DVD s Videos Furs Jewelry His wedding ring Her wedding ring Costume Jewelry Other Jewelry Hobby Equipment Sports Equipment Firearms Camping Equipment Hunting Equipment Fishing Equipment Cameras, photographic Equipment Other Hobby Equipment Insurance and Pension Insurance Policy Q Term Q whole life Q (Company Name) Insurance Policy Q Term Q whole life Q (Company Name) Annuities (Name of Issuer) IRA Educational IRA 401K 401K Loan value Loan value Page 7

8 Interest in Pension or profit sharing plans Interest in Pension or profit sharing plans Business Ownership or Receivables Stocks and interests in incorporated/unincorporated business. Stocks and interests in incorporated/unincorporated business. Interest in Partnerships/Joint ventures Bonds Accounts receivable Patents, copyrights, other intellectual property Licenses, franchises, or customer lists Alimony, Estates, Litigation Alimony or family support to which you are entitled Alimony or family support to which you are entitled Other liquidated debts owed to you, including tax refunds. Equitable or future interests or life estates. Interest in estate of descendant or life insurance plan or trust. Other contingent/unliquidated claims, including counterclaims. Property with Titles Boats, motors and accessories Aircraft and accessories Automobiles, trucks, trailers and accessories (please list year, make, and model) Page 8

9 Business Office equipment or Tools of your Trade or Business Office or Business supplies Machinery, fixtures etc. for business (small items can be grouped together, if extensive attach a list). Inventory (please attach a complete list of items) How much is collectible? Customer Lists (description) Animals (if extensive attach a list) Crops Growing or harvested Farming Equipment and implements (if extensive attach a list) Farm supplies, chemicals, feed (if extensive attach a list) Other personal property of any kind not otherwise listed Page 9

10 Creditors List below all debts that you owe, or that creditors claim you owe. Be as complete and thorough as possible. A bankruptcy will provide you no protection on bills not listed. If additional space is needed please attach additional pages. Next to Who s debt mark as follows: h = husband, w = wife, b = both, and/or co = cosigner. On secured debts only next to Other mark as follows: r = reaffirm (want to keep collateral and continue paying for it), s = surrender (want to give the item(s) back). Also, next to Other mark as follows: c = contingent (not owed until certain event occurs), u = unliquidated (amount can't be calculated yet), d = disputed (we don't owe the bill or don t know what the bill is for). Page 10

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17 Leases and Contracts - Schedule G List below any ongoing leases or contracts that are you are party to (even if you are current on your payments). Include residential, car and business leases, and service or business contracts (like cell phones, gym membership, cable, satellite, and storage units). Nature and Description of Contract Name and Address of Other Party/Parties Date that Contract Expires Rent /Month Expires: Keep the Contract? No Yes Nature and Description of Contract Name and Address of Other Party/Parties Date that Contract Expires Cell Phone(s) /Month Expires: Keep the Contract? No Yes Nature and Description of Contract Name and Address of Other Party/Parties Date that Contract Expires Expires: Keep the Contract? No Yes Nature and Description of Contract Name and Address of Other Party/Parties Date that Contract Expires Expires: Keep the Contract? No Yes Co-Signers - Schedule H List below any co-debtors on any obligations that you may have from Section 3 above. Nature and Description of Obligation Name and Address of Other Party/Parties Date that Contract Expires Page 17

18 Current Income - Schedule I Marital Status Married Single Divorced Separated Widowed List all dependents of you and your spouse, their ages, and their relationship to you Name Age Relationship in Household Filer s Income 1. What is your occupation 2. Name and Address of your employer: 3. How long have you been employed there? 4. What is the gross amount of your paycheck, before taxes, and other deductions are taken out? 5. How often do you get paid? once a week every two weeks twice a month once a month other 6. Do you receive overtime pay outside of your salary? If so, how much per month average? 7. How much is taken out of each paycheck for taxes and social security? 8. How much is taken out for insurance? 9. How much for union dues? 10.Are there other deductions? If so, what are they and how much? Do you receive: a) income from business operations outside of your regular paycheck listed above? If so, what is the business and how much do you receive per month? b) income from real estate property? If so, how much per month? No Yes c) interest or dividends? If so, how much per month? No Yes d) alimony or family support payments for your use or for the care of your dependents? If so, how much per month? No Yes e) social security or other forms of monetary government assistance? No Yes f) retirement or pension money? No Yes Do you have any other sources of income not listed? Partner s Income 1. What is your occupation 2. Name and Address of your employer: 3. How long have you been employed there? 4. What is the gross amount of your paycheck, before taxes, and other deductions are taken out? 5. How often do you get paid? once a week every two weeks twice a month once a month other 6. Do you receive overtime pay outside of your salary? If so, how much per month average? 7. How much is taken out of each paycheck for taxes and social security? 8. How much is taken out for insurance? 9. How much for union dues? 10.Are there other deductions? If so, what are they and how much? Do you receive: a) income from business operations outside of your regular paycheck listed above? If so, what is the business and how much do you receive per month? b) income from real estate property? If so, how much per month? No Yes c) interest or dividends? If so, how much per month? No Yes d) alimony or family support payments for your use or for the care of your dependents? If so, how much per month? No Yes e) social security or other forms of monetary government assistance? No Yes f) retirement or pension money? No Yes Do you have any other sources of income not listed? Are you or your spouse expecting any increase or decrease in salary of more than 10% in the next year? If so, explain. Page 18

19 Current Monthly Expenses - Schedule J Do you and your spouse maintain separate households? If yes, fill one column for the Debtor and one for the Joint Debtor. If not, fill only the Debtor column. If you know that you are paying less than you should for certain items (such as food or clothing) or you need something (like medical insurance, an operation, your own place to live, or a new car) enter the correct amount of that expense on the appropriate line surrounded by parentheses ( ) or at the bottom of this form. Attach to this questionnaire proof of such need or a hand written explanation if appropriate. Debtor Joint Debtor 1. Your rent or your home mortgage Does that amount include real estate taxes? No Yes Does it include property insurance? No Yes 2 Electricity and heating 3. Water and sewage 4. Telephone service/long distance 5. Do you have any other utility bills? If so, what and how much per month? 6. Home maintenance, including repairs and general upkeep 7. Food 8. Clothing 9. Laundry and dry cleaning 10. Medical and dental expenses 11. Transportation (not including car payments) 12 Entertainment, recreation, newspapers, magazines 13. Charitable contributions (attach proof of payment) 14 Insurance not deducted from paycheck a) homeowner s or renter s insurance b) life insurance c) health insurance d) auto insurance e) other insurance 15. Taxes not deducted from paycheck 16. Installment payments for car, furniture, etc. (Specify) 17. Alimony, maintenance, support paid to others 18. Payments for support of dependents not living at home 19. Expenses from operation of business 20. Mandatory payroll deductions not already listed: 21. Court ordered payments not already listed: 22. Education necessary to maintain employment 23. Education for a physically or mentally challenged child 24. Childcare 25. Disability insurance (if not listed on line 14 above) 26. Health Savings Accounts 27. Care for elderly, chronically ill, or disabled family members 28. Protection from family violence 29. Education expense for children under 18 Page 19

20 30. Non-mandatory contributions to retirement accounts 31. Other expenses not listed above Are you or your spouse expecting any increase or decrease in expenses of more than 10% in the next year? If so, explain. Monthly Business Income and Expenses If you have any earning from self employment or business activities and your expenses exceed 200 per month, complete the following for each activity. Do not include information already included in your budget above even if you deduct such amounts on your taxes. 1. Gross business income for the 12 months prior to filing 2. Estimated future average monthly income 3. Net employee payroll (other than debtor) 4. Payroll taxes 5. Unemployment Taxes 6. Worker s Compensation 7. Other Taxes 8. Inventory Purchases (including raw materials) 9. Purchase of Fee/Fertilizer/Seed/Spray 10. Rent (other than debtors principle residence) 11. Utilities 12. Other Expenses and Supplies 13. Repairs and Maintenance 14. Vehicle Expenses 15. Travel and Entertainment 16. Equipment Rental and Leases 17. Legal/Accounting/Other Professional Fees 18. Insurance 19. Employee Benefits (e.g. pension, medical, etc.) Total Monthly Expenses (add lines 3 through 27) 29. Average Net Monthly Income (line 28 from line 2) Page 20

21 Statement of Financial Affairs If you are filing jointly with your spouse, include information about both you and your spouse. If you are filing under chapter 12 or 13, and you are married and not separated, you must provide information about your spouse even if you they are not filing with you. If you have no information to report for a question, check the NONE box. 1. Gross income from employment State your gross income from employment or operation of a business (husband s and wife s income should be listed separately): If you have not received an income from employment during the two years immediately preceding this calendar year, check this box: Period Amount Source Husband/Wife Year to Date Income other than from employment State the amount of income received other than from employment or operation of business during the two years immediately preceding the commencement of this case (e.g. unemployment, disability insurance, social security, etc.): Period Amount Source Husband/Wife During the last year Year before last 3. Payments to creditors a) List all payments on loans, installment purchases of goods or services, and other debts, aggregating more than 600 (for example more than 200 per month for the last three months) to any creditor made within 90 days immediately preceding the commencement of this case. Name and Address of Creditor Dates of Payments Amount Paid Amount Still Owed Page 21

22 b) List all payments made within one year immediately preceding the commencement of this case to creditors who were insiders. ( Insiders include your relatives, your business partners and their relatives, your corporations, your affiliates, or anyone who has personal knowledge of your financial affairs.) Name and Address of Creditor and Relationship to You Dates of Payment Amount Paid Amount Still Owed 4. Suits, executions, garnishments and attachments a) List all lawsuits and administrative proceedings to which you are or were a party within one year preceding the filing of this case. Please attach copies of any pleadings to this questionnaire. Caption of Suit and Case Number Nature of Proceeding Court of Agency and Location Status or Disposition b) Describe all property that has been garnished, seized, or attached under any legal or equitable process within one year immediately preceding the commencement of this case. Name and Address of Person/Company for Whom the Property Was Seized (Creditor) Date of Seizure Description and Value of Property 5. Repossessions, foreclosures, and returns List all property that has been repossessed by a creditor, sold at a foreclosure sale, transferred through a deed in lieu of foreclosure, or returned to the seller, within one year immediately preceding the commencement of this case. Name and Address of Creditor Date of Repossession, Foreclosure, Transfer or Return Description and Value of Property Page 22

23 6. Assignments and receiverships a) Describe any assignment of property for the benefit of creditors (i.e. property that you have given to anyone with the intent that it pay one or more debts that you owe) made within 120 days immediately preceding the commencement of this case. Name and Address of Assignee Date of Assignment Terms of Assignment/Settlement b) List all property which has been in the hands of a custodian, receiver, or court-appointed official within one year immediately preceding the commencement of this case. Name and Address of Custodian Name and Location of Court, Case Title and Number Date of Order Description and Value of Property 7. Gifts List all gifts or charitable contributions made within one year immediately preceding the commencement of this case except ordinary and usual gifts to family members aggregating less than 200 in value per individual family member and charitable contributions aggregating less than 100 per recipient. Name and Address of Recipient Relationship to You, if Any Date of Gift Description and Value of Gift 8. Losses List all losses from fire, theft, gambling or other casualty within one year immediately preceding the commencement of this case or since the commencement of this case. Description and Value of Property Description of Circumstances and Amount Covered by Insurance, if Any Date of Loss Page 23

24 9. Payments related to debt counseling or bankruptcy List all payments made or property transferred by or on behalf of the debtor to any persons, including attorneys, for consultation concerning debt consultation, relief under the bankruptcy law or preparation of the petition in bankruptcy within one year immediately preceding the commencement of the case. Name and Address of Payee Date of Payment Name of Person Who Paid, if Not You Amount of Money/Description and Value of Property Philip G. Jones 10. Other transfers, (including sale of your property) List all other property, other than property transferred in your ordinary course of business or financial affairs, transferred either absolutely or as a security within one year immediately preceding the commencement of this case. Also list any property you transferred into a trust (or similar device) in the last 10 years. Name and Address of Transferee and Relationship to You Date of Transfer Description of Property Transferred and Value Received 11. Closed financial accounts List all financial accounts and instruments held in your name or for your benefit which were closed, sold, or otherwise transferred within one year immediately preceding the commencement of this case. Name and Address of Institution Type and Number of Account & Final Balance Amount and Date of Sale or Closing 12. Safe deposit boxes List each safe deposit or other box or depository in which you have or have had securities, cash, or other valuables within one year immediately preceding commencement of this case. Name and Address of Bank or Other Depository Name and Address of Those With Access to Box or Depository Description of Contents Date of Transfer, if Any Page 24

25 13. Setoffs List all setoffs (i.e. when one of your creditors also owes you money) made by any creditor, including a bank, against a debt or deposit of yours within 90 days preceding the commencement of this case. Name and Address of Creditor Date of Setoff Amount of Setoff 14. Property held for another person List all property that you hold or control that is owned by another person. Name and Address of Owner Description and Value of Property Location of Property 15. Prior address of debtor If you have moved within the three years immediately preceding the commencement of this case, list all residences during the last two years, excluding your present address. Address Your Name at the Time Dates of Occupancy 16. Spouses and Former Spouses If you reside or resided in a community property state, commonwealth, or territory (including Alaska, Arizona, California, Idaho, Louisiana, Nevada, New Mexico, Puerto Rico, Texas, Washington, or Wisconsin) within the eight-year period immediately preceding the commencement of the case, identify the name of your spouse and of any former spouse who resides or resided with you in the community property state. Name 17. Environmental Information. For the purpose of this question, the following definitions apply: "Environmental Law" means any federal, state, or local statute or regulation regulating pollution, contamination, releases of hazardous or toxic substances, wastes or material into the air, land, soil, surface water, groundwater, or other medium, including, but not limited to, statutes or regulations regulating the cleanup of these substances, wastes, or material. "Site" means any location, facility, or property as defined under any Environmental Law, whether or not presently or formerly owned or operated by the debtor, including, but not limited to, disposal sites. "Hazardous Material" means anything defined as a hazardous waste, hazardous substance, toxic substance, hazardous material, pollutant, or contaminant or similar term under an Environmental Law. Page 25

26 a. List the name and address of every site for which you received notice in writing by a governmental unit that it may be liable or potentially liable under or in violation of an Environmental Law. Indicate the governmental unit, the date of the notice, and, if known, the Environmental Law: Name and Address of Date Environmental Site Name and Address Governmental Unit of Notice Law b. List the name and address of every site for which you provided notice to a governmental unit of a release of Hazardous Material. Indicate the governmental unit to which the notice was sent and the date of the notice. Name and Address of Date Environmental Site Name and Address Governmental Unit of Notice Law c. List all judicial or administrative proceedings, including settlements or orders, under any Environmental Law with respect to which you are or were a party. Indicate the name and address of the governmental unit that is or was a party to the proceeding, and the docket number. Name and Address of Governmental Unit Docket Number Status or Disposition 18. Nature, location and name of business a. If the debtor is an individual, list the names, addresses, taxpayer identification numbers, nature of the businesses, and beginning and ending dates of all businesses in which the debtor was an officer, director, partner, or managing executive of a corporation, partnership, sole proprietorship, or was a self-employed professional within the six years immediately preceding the commencement of this case, or in which the debtor owned 5 percent or more of the voting or equity securities within the six years immediately preceding the commencement of this case. If the debtor is a partnership, list the names, addresses, taxpayer identification numbers, nature of the businesses, and beginning and ending dates of all businesses in which the debtor was a partner or owned 5 percent or more of the voting or equity securities, within the six years immediately preceding the commencement of this case. If the debtor is a corporation, list the names, addresses, taxpayer identification numbers, nature of the businesses, and beginning and ending dates of all businesses in which the debtor was a partner or owned 5 percent or more of the voting or equity securities within the six years immediately preceding the commencement of this case. Taxpayer Beginning and End Name I.D. Number Address Nature of Business Dates of Operation b. Identify any business listed in response to subdivision a., above, that is "single asset real estate" as defined in 11 U.S.C Name Address The following questions, #19-25, are only to be answered if you are a corporation or partnership or if you have been, in the six years immediately preceding this case, an officer, director, managing executive, or owner of more than 5% of the voting securities of the corporation; a partner, other than a limited partner, of a partnership; a sole proprietor, or otherwise self-employed. Page 26

27 19. Books, records, and financial statements a. List all bookkeepers and accountants who, within the six years immediately preceding the filing of this bankruptcy case, kept or supervised the keeping of books of account and records. Name and Address Dates Services Rendered b. List all firms or individuals who, within the two years immediately preceding the filing of this bankruptcy case, have audited the books of account and records, or prepared a financial statement of the debtor. Name Address Dates Services Rendered c. List all firms or individuals who, at the time of the commencement of this case, were in possession of your books of account and records. If the records are not available, explain. Name and Address Comments d. List all financial institutions, creditors and other parties, including mercantile and trade agencies, to whom a financial statement was issued by the debtor within two years immediately preceding the commencement of this case. Name and Address Date Issued 20. Inventories a. List the dates of the last two inventories taken of your property, the name of the person who supervised the taking of each inventory, and the dollar amount and basis of each inventory. Dollar Amount of Inventory Date of Inventory Inventory Supervisor (specify cost, market, or other basis) Page 27

28 b. List the name and address of the person possessing the records of each of the two inventories reported in a.) above. Date of Inventory Name and Address of Custodian of Inventory Records 21. Current partners, officers, directors, and shareholders a. If your business is a partnership, list the nature and percentage of partnership interest of each member of the partnership. Name and Address Nature of Interest Percentage of Interest b. If your business is a corporation, list all officers and directors of the corporation, and each stockholder who directly or indirectly owns, controls, or holds 5 % or more of the voting securities of the corporation. Nature and Percentage Name and Address Title of Stock Ownership 22. Former partners, officers, directors and shareholders a. If your business is a partnership, list each member who withdrew from the partnership within one year immediately preceding the commencement of this case. Name and Address Date of Withdrawal b. If your business is a corporation, list all officers or directors whose relationship with the corporation terminated within one year immediately preceding the commencement of this case. Name and Address Title Date of Termination Page 28

29 23. Withdrawals from a partnership or distributions by a corporation If your business is a partnership or corporation, list all withdrawals or distributions credited or given to an insider, including compensation in any form, bonuses, loans, stock redemptions, options exercised and any other perquisite during one year immediately preceding the commencement of this case. Name and Address of Date and Purpose Amount of Money or Description Recipient, and Relationship to You of Withdrawal and Value of Property 24. Tax Consolidation Group. If the debtor is a corporation, list the name and federal taxpayer identification number of the parent corporation of any consolidated group for tax purposes of which the debtor has been a member at any time within the six-year period immediately preceding the commencement of the case. Name of Parent Corporation Taxpayer Identification Number 25. Pension Funds. If the debtor is not an individual, list the name and federal taxpayer identification number of any pension fund to which the debtor, as an employer, has been responsible for contributing at any time within the six-year period immediately preceding the commencement of the case. Name of Pension Fund Taxpayer Identification Number Page 29

30 Financial Agreement with Attorney Chapter 7 - The services included in a Chapter 7 include: the initial consultation, a second consultation to review the questionnaire, preparation of bankruptcy statements and schedules, a third consultation in preparation for the meeting of creditors, attendance at the meeting of creditors, providing phone confirmation of bankruptcy filing to enquiring creditors, up to four phone consultations with the client, mailing the statement of intent to secured creditors and lessors, negotiating reaffirmation agreements at the first meeting of creditors, correspondence to client regarding the progress of the case, preparing notices of address change, phone consultations with the trustee and OUST, correspondence to the trustee and OUST, sending notices of bankruptcy filing as appropriate, and attendance at 2004 exams. In a chapter 7 you must pay in full before your case can be filed. Please select from the following all that apply: Consumer Case Base Fee Foreclosure Pending More than 30 Creditors Individual Additional fee Additional fee Joint Substantial Business Activity/Debt Income in Excess of Utah Median Additional fee Additional fee Business Case Base Fee Foreclosure Pending More than 30 Creditors No Assets Additional fee Additional fee Assets Chapter 13 - The services included in a Chapter 13 include: the initial consultation, a second consultation to review the questionnaire, preparation of bankruptcy statements, schedules, and plan, a third consultation in preparation for the meeting of creditors, attendance at the meeting of creditors, providing phone confirmation of bankruptcy filing to enquiring creditors, up to four phone consultations with the client, correspondence to client regarding the progress of the case, preparing notices of address change, phone consultations and correspondence with the trustee, sending notices of bankruptcy filing as appropriate, responding to motions when there is a valid supportable defense, proof of claims review, preparation of claims objection documents, and other normal post confirmation services for a period of 6 months. A portion of your fee to the attorney will come out of your regular monthly payments to the court. However, in the event you do not make all of your payments to the court, you will still owe the attorney the difference between what the court has paid him and the cost of his services. In a chapter 13 you must pay the down indicated below before your case can be filed. Please check one of the boxes below: Bankruptcy Base Fee 3, Individual (1100 down, 2,047 in plan) 3, Joint (1200 down, 2,016 in plan) Optional Services - The attorney will perform the following optional services for the amounts indicated, payable in advance. Please select those that apply: 522(f) Motion (Lien Avoidance) Obtain Tax Transcripts Obtain Post Bankruptcy Credit Review Individual Individual Joint Joint Other Terms - Please be aware that no work will be performed and you are not a client until you return the properly completed questionnaire, all of the applicable documents, pay the retainer, and sign this agreement. A non-refundable retainer is due upon return of the questionnaire in all cases. The base fee in both Chapter 7 and Chapter 13 includes payment of the court filing fee, the briefing class, the financial education class, and credit reports from the three major bureaus. Any services beyond the items set forth herein will result in additional charges. For example, the filing of an amendment requires an additional fee (which must be paid before the amendment is filed). By signing this agreement you understand that the attorney is not obligated to perform any services beyond those enumerated above, and you expressly agree that your attorney is not obligated to represent you in adversary proceedings. Any services agreed to be performed by the attorney beyond those set forth on this page require a separate written contract before the attorney will perform them and will involve additional cost. All payments must be made in the form of cash, cashiers check or money order. Personal checks will not be accepted. The attorney does not maintain Client Trust Accounts. All funds received are considered earned upon receipt. By signing below, I agree to the above terms and conditions and state that they represent the sole agreement between the parties. I also state that the information I have provided to the attorney is true, accurate, and complete. Date Your Signature Spouses Signature 02/07