LAW OFFICES OF. Main Office: 4905 Chiquita Blvd. S., Suite 103 Cape Coral, Florida Telephone: (239) Facsimile: (888)

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1 Naples Office: 999 Vanderbilt Beach Road, Suite 200 Naples, Florida Telephone: (239) Facsimile: (888) LAW OFFICES OF JUAN J. PILES Main Office: 4905 Chiquita Blvd. S., Suite 103 Cape Coral, Florida Telephone: (239) Facsimile: (888) CLIENT QUESTIONNAIRE Miami Office: 255 Westward Drive Miami Springs, Florida Telephone: (305) Facsimile: (888) Thank you very much for retaining The Law Office of JUAN J. PILES, ESQUIRE for your legal needs. Please fill out this form as completely as possible so we can provide you with helpful and accurate advice. Under the law, you must list each and every debt, including debts to friends and relatives. If you need more space, please use the back side of the paper. Please also remember to list every creditor to whom you are obligated. Similarly, you should list debts even if you think the creditor has written off the loan or if you think that someone else may pay the bill in the future. We need copies of the following: All credit card statements (one statement per creditor); All collection company letters; All medical bills; 2011 AND 2012 complete tax returns; Proof of Income: 6 months paystubs OR unemployment checks OR social security checks OR disability checks; Copy of auto registration, title and insurance, if you have a car in your name; Last three months bank statements (6 months for Chapter 13); Copy of any retirement account (401k, IRA, 403B, etc.) statement for the last sixty (60) days; Copies of any lawsuits against you, including, repossessions, foreclosures, small claims, etc.; Payoff statement from Lender for any mortgage that you are a mortgagor; and Payoff statement from Lender for any vehicles financed. ****PLEASE DO NOT STAPLE ANY OF YOUR COPIES OR STATEMENTS**** We ask that you complete this questionnaire to the best of your ability. We do need all of the information requested to accurately file the petition and avoid any excessive questions at the time of the 341 creditor hearing. Finally, you are required to take an online Pre-Filing Credit Course before we file your bankruptcy. You will also need to take an online Pre-Discharge Debtor Education Course after the filing of the petition. Here is the website we recommend to our clients: ($5 pre-filing per person / $15 post-filing - per household) or ($7.95 individual) or (Spanish).

2 PERSONAL INFORMATION Today s date: CHAPTER: FR SALE DATE: REPO: GARNISHMENT: YES / NO BK FILE DATE: Your Name (as it appears on Soc. Sec. Card): Date of Birth: Maiden name/former names: Social Security Number: Marital status: Your address: Rent Own Are the mortgage payments up to date? Home phone: Work phone: Cell/Beeper: address: Name and # of someone who could reach you in an emergency: Spouse's Name: Date of birth: Spouse's maiden/former name: Spouse's social security number: _ Spouse's work phone: Spouse's home address and home phone (if different from yours): How long have you lived at your home address: If less than 3 years, please list previous addresses and dates lived, beginning with the most recent: Dates: Dates: Dates: Dates:

3 Income Information Marital Status: Live Apart: YES / NO Yourself Spouse Job title/occupation: Employer: How long there: Payroll address: City, ST Zip Payroll office phone #: Employer s Telephone #: Income (hourly/salary): $ $ Date next paycheck Children & Step-children which you maintain/support Name Age Relationship Does child live with you? Child support $ paid/received Expected changes in income: Describe when & why:

4 Income & Expenses The new bankruptcy law requires that we analyze the household income. Please photocopy each and every pay stub for the past six months and attach. If you have income from other sources during this period (unemployment, dividends, one-time payments, etc.), please photocopy whatever documentation you have. If you are self employed, you will need a spreadsheet detailing gross income, itemized business expenses and other deductions. Household Expenses the Bankruptcy Courts now require supporting documentation for all claimed expenses. Please save receipts in case the Court requests proof of expenses. Household expenses Attorney's Notes Rent/mortgage payments Property Taxes (if not included in Mortgage Payment) Property Insurance (if not included in Mortgage Payment) Electric bill (average) Gas bill Water/sewer Telephone Cell phone #1 Cell phone #2 Cell phone #3 Internet service Cable TV Home maintenance Food Clothing

5 Laundry/dry cleaning Medical/dental (deductibles and non-reimbursed only) Gasoline/bus fare Oil changes/tires Charity/church (receipts will be needed) Personal property insurance Life insurance Disability insurance Long term care insurance Health insurance (not deducted from pay) Auto insurance Non-payroll taxes Car/truck payment #1 Car/truck payment #2 Car/truck payment #3 Alimony paid Child support paid out Education expenses (child must be <18) Child care expenses Care for elderly Any other expenses not listed above

6 Has the IRS, State of Florida or any other taxing entity ever advised you that a tax lien has been filed against you? Do you owe taxes to any governmental entity? If so, please provide copies of statements or demand letters. Has a lawsuit ever been filed against you - has a sheriff's deputy ever served a summons upon you? Lawsuit filed against you by: Reason for lawsuit & date lawsuit served on you County where filed Case number Status now Have your wages ever been garnished? Who is garnishing When did garnishment begin How much $ taken to date Is garnishment ongoing Who is plaintiff s lawyer? Have you ever lost a house to a mortgage foreclosure? Mortgage company/lender Foreclosing law firm When was house sold Address of lost property Status now

7 Please identify any real estate (including vacant land) that is in your name. Property address Number of Mortgages Purchase price & Date purchased Value Total debt owed on property Keep or Surrender Please identify any cars, trucks, motorcycles, boats and RVs that you own. Year/make/model of vehicle & mileage Date purchased In whose name Value now Total debt owed on property Keep or Surrender Are you currently involved in a car accident claim, workers compensation claim or any other claim that may result in money damages payable to you? Please describe: Please identify any bank accounts you own. Name of bank Checking/ savings? In whose name Current balance Any other loans or credit cards with this lender?

8 Other assets not yet described (i.e. boats, stocks/bonds, antiques, home furnishings (sofa, loveseat, bedroom set, ding room set, television, cameras, computers, musical instruments, valuable collections, insurance policies with cash value, guns, sporting equipment, jewelry, etc.) Asset description Age/Year of asset? Who owns this asset? Has asset been pledged as collateral for a loan? Living Room: Sofa / Loveseat / Armchair / coffee table / Entertainment Center / end tables TV (plasma, LCD, tube) Dining Room: Table / chair / china cabinet Master Bedroom: King bed / Queen Bed / dresser night stands / armoire TV (plasma, LCD, tube) Guest Bedroom 1: King bed / Queen Bed / dresser night stands / armoire TV (plasma, LCD, tube) Guest Bedroom 2: King bed / Queen Bed / dresser night stands / armoire TV (plasma, LCD, tube) Guest Bedroom 3: King bed / Queen Bed / dresser night stands / armoire TV (plasma, LCD, tube) Family Room: TV (plasma, LCD, tube) APPLIANCES: Refrigerator, Stove, Microwave, Washer, Dryer Firearms, rifles, guns, photographic equipment: GARAGE ITEMS: Jewelry with precious stones, watches, etc.: Security Deposit (with Landlord): Computers (desktop or laptop), printers, etc. Pets: TAX REFUND: Please state the date and amount of tax refund received last year & expected this year.

9 Have you ever lost a car to repossession? Car finance company When was vehicle seized Vehicle make/model Have you received notice that you still owe money on vehicle? Miscellaneous During the last 60 days, have you done any of the following Used credit cards Yes/ No Details/Explanation Taken cash advances Taken out any new loans Gave away or sold any property worth more than $600 Have you transferred any property in the last four years Have you paid any creditors, family members, friends or business partners in the last two years Does anyone owe you any money or is holding property for you Have you paid anyone more than $600 in the past six months Have you been in an accident in the last four years Do you have any unpaid medical bills? If so, please provide copies Did you purchase electronics or furniture with a store credit card? (ex. Best Buy, Rooms to Go, etc.) Do you have any student loans?

10 Have you ever filed a Chapter 7 or a Chapter 13 bankruptcy before? Type of bankruptcy (Ch. 7 or Ch. 13 Date filed Was case completed or dismissed? When was case closed by Court Case number Former BK lawyer BANKRUPTCY DISCLOSURE 1. Exemptions: You are entitled to the following exemptions for your personal property: a. $1, per debtor for vehicles (vehicle exemptions are determined by title owners $1,000 per debtor on title). Exemption applies to EQUITY on vehicle, not total value. b. $1, per debtor for personal property (home furnishings, bank accounts, jewelry, clothes, tax refunds, etc.) c. BONUS: $4, per debtor if you do not claim a homestead exemption 2. Incomes Taxes: The Trustee may claim your tax refund. This normally happens if your assets exceed the exemptions listed above. It is advisable to file your tax return and spend your refund on normal living expenses prior to filing for bankruptcy (cash withdrawals are strongly discouraged). a. NOTE: Chapter 13 debtors: The Trustee may keep your tax refunds during the bankruptcy. One suggestion is to lower your withholdings to reduce and/or eliminate any tax refunds. You may also want to contribute to your retirement account at work to reduce disposable income. 3. Vehicles: The court values all vehicles at NADA retail value. An appraisal is recommended if your vehicle has equity above the exemptions listed above. The fee for an auto appraisal is $60 per vehicle. 4. DATE OF FILING: You must coordinate with our office for the date of filing. The date of filing should be a date when your account balance(s) are the lowest. You should not file on the date a paycheck is received or a deposit is made to your bank account(s). You should file after all outstanding checks have cleared the bank account(s). The undersigned hereby acknowledge receipt of the above disclosure: I certify that the information I have provided in this questionnaire is true and correct, under penalty of perjury. Date Date Signature Signature

11 DISCLOSURE CERTIFICATE I, the undersigned, hereby attest and affirm that all debts, whether joint debts, co-signed debts, claims or lawsuits for collection of debts, whether disputed or not, have been listed on my questionnaire. I acknowledge that my attorneys rely on the information provided in this questionnaire in order to assist and advise me, and that it is my responsibility to provide my attorneys with a full, complete and accurate financial disclosure. I further agree to update my attorneys with regard to any incomplete information contained herein. I further acknowledge that in the event a creditor is omitted from any bankruptcy petition filed by my attorneys as a result of an omission on this questionnaire, I will not have the protection of the Bankruptcy Court from actions by that creditor. MANY CREDIT REPORTS DO NO INCLUDE WRITE-OFFS OR FORECLOSURE PROPERTY DEFICIENCES. PLEASE VERIFY THE CREDITOR LIST ON THE BANKRUPTCY TO BE FILED TO ENSURE ALL CREDITORS ARE LISTED. FAILURE TO LIST A CREDITOR IN THE BANKRUPTCY WILL RESULT IN THE DEBT NOT BEING DISCHARGED. THE CREDITOR MAY PURSUE COLLECTION AGAINST YOU AFTER BANKRUPTCY. Date Date Signature Signature

12 Exhibit A CONSUMER AUTHORIZATION AND RELEASE I hereby authorize First Advantage CREDCO, LLC ( FAC ) to obtain my consumer report/credit information (hereinafter referred to as Report ) from one or more of the three national credit repositories (Equifax, Experian, Trans Union) and provide a copy of the Report to my attorney, ( Attorney ) for Attorney to perform due diligence and verification pursuant to the Bankruptcy Abuse, Prevention, and Consumer Protection Act of This authorization is intended to comply with a consumer report request as set forth in 15 U.S.C. 1681b(a)(2). I acknowledge that the Report is provided AS IS AND THAT FAC MAKES NO REPRESENTATION OR WARRANTY, EXPRESS OR IMPLIED, INCLUDING, BUT NOT LIMITED TO, IMPLIED WARRANTIES OF MERCHANTABILITY OR FITNESS FOR A PARTICULAR PURPOSE AND IMPLIED WARRANTIES ARISING FROM A COURSE OF DEALING OR A COURSE OF PERFORMANCE WITH RESPECT TO THE ACCURACY, VALIDITY, OR COMPLETENESS OF THE REPORT OR THAT IT WILL MEET MY NEEDS AND FAC EXPRESSLY DISCLAIMS ALL SUCH REPRESENTATIONS AND WARRANTIES. I recognize that the accuracy, validity or completeness of the Report provided by FAC is not guaranteed by FAC and I hereby release FAC and FAC s parent, sister, affiliated companies, successors and assigns and its and their directors, officers, agents, employees and independent contractors (collectively, FAC s Affiliates ) from any liability for any negligence in connection with the preparation of the Report and from any loss, damages, expenses, costs or obligations of any kind and nature whatsoever suffered by me resulting directly or indirectly from the inaccuracy, invalidity or incompleteness of the Report. I covenant not to sue or maintain any claim, cause of action, demand, cross action, counterclaim, third party action or other form of pleading against FAC or FAC s Affiliates for damages based upon the inaccuracy, invalidity or incompleteness of any Report provided by FAC hereunder. If one or more of the provisions, or a portion of a provision of this document are held for any reason to be invalid, illegal or unenforceable, such invalidity or illegality or unenforceability will not affect any other provisions of this document, and this document will be construed as if such invalid, illegal or unenforceable provision had not been contained herein. Date: (Signature) (Print Name) *160* *APR08J3* Bankruptcy Program AFS Page 5 of 10 COMP-BPAFS-APR08-J