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1 Thanks for making an appointment to see us! Please fill out the following forms before your first bankruptcy consultation at Friedman Iverson. These forms help us understand your financial issues and quickly find your best options. ou can fill this PDF out on your computer using Acrobat or you can print them and complete by hand. Please try to send these forms via or fax before your first meeting. If you don t have the chance, bring printed versions when you come in. Please send completed forms: By bankruptcy@friedmaniverson.com By fax: (612) Questions: bankruptcy@friedmaniverson.com Call: (612)

2 Document Checklist ecessary documents: These are the documents we ll need to evaluate your case. If you don t bring all of them, we may not be able to have our meeting. If there are specific documents you can t find, please contact us in advance of your meeting. All forms marked in this packet Drivers license and proof of social security number our last six months of pay stubs, or if you can t gather them, a paycheck printout from your employer If you are self-employed, a profit and loss statement from the past six months Documentation of any other income source, including any government benefits If you share expenses with a spouse/partner, six months of pay stubs for your partner Federal and state income tax returns for 2011 and 2012 with all attachments (W2s, 1099s, etc.) If you already have one, a recent credit report Any lawsuit, garnishment or foreclosure papers you have received A voided check, if you want to pay your bankruptcy fees through automatic debit (which gives you a $100 discount) Helpful documents: It s helpful, but not necessary, to bring these documents to your first meeting. ou may scan/ or fax these documents to us after your first meeting. Most recent bank statement for each bank account in your name The title to any vehicle in your name Balance statements for all retirement accounts and summary plan descriptions for any pensions Any retirement loan statements, showing the balance owed, the duration of each loan, and the monthly payment Copies of life insurance policies, term or whole life Stock certificates and statements for stock accounts and brokerage accounts Most recent mortgage, second mortgage, or home equity loan statement, showing balance due to pay the loan off in full If you have it, appraisal or broker price opinion showing the value of your house Bills for any debts that are not listed on your credit report, including utility and medical bills Recent correspondence from debt collectors Student loan statements Any papers related to tax debt or installment agreements If you own a business: Monthly profit and loss statement for the past six months Current balance sheet Business tax returns Inventory list List of business debts

3 Personal Information OUR IFO SPOUSE/PARTER IFO (if applicable) Full name: Former/other name used: Social Security umber: Date of Birth: address: Occupation: ame/address of employer: Length of time employed: Home Street Address City/State ZIP Telephone number: Alternate phone number: List all addresses you have had in the last three years and the dates you lived there: Full Address City, State ZIP Date Moved In Date Moved Out DEPEDETS Relationship Age

4 Income worksheet Gross monthly income Gross wages Estimated overtime Bonuses/commissions SUBTOTAL OU SPOUSE/PARTER Take home pay Other Income et business income Rental income Interest and investments Spousal maintenance, child support Social security benefits Other government assistance Pension and retirement income Other monthly income (describe): Other monthly income (describe): SUBTOTAL OF OTHER ICOME AVERAGE MOTHL ICOME + COMBIED HOUSEHOLD ICOME

5 Expenses worksheet RET/UTILITIES Rent or mortgage Electricity Heat Water Trash Cell phone Landline Cable TV Internet Other (describe) Other (describe) HOUSEHOLD ISURACE Homeowner s or renter s Life (not deducted from pay) Auto Other (describe) Other (describe) TAXES Real estate taxes (not escrowed) Estimated quarterly payments (only if self-employed) Installment agreements HOUSEHOLD HOUSEHOLD Home maintenance Food Clothing Laundry and dry cleaning Personal care (haircuts, toiletries, etc.) Housekeeping supplies Car fuel Car maintenance Public transportation and taxis Child care Kids activities Entertainment and activities Gym membership and sports LOA PAMETS Car 1 Car 2 Student loans Other (describe) OTHER Spousal maintenance and child support Financial support of other family members Pet care Charitable contributions MEDICAL Health insurance (not deducted from paycheck) Copays and prescriptions Eyeglasses/contacts TOTAL

6 Property Do you own a home? es o Address: Street City, State ZIP First mortgage company: Second mortgage company: First mortgage balance: Second mortgage balance: Other liens: Vehicle 1: ear Make Mileage Condition Vehicle 2: ear Make Mileage Condition Vehicle 3: ear Make Mileage Condition BAK ACCOUT (any account with your name): Bank Branch address Balance Joint holder? Type Bank/brokerage Balance RETIREMET STOCK/BROKERAGE ADDITIOAL ACCT LIFE ISURACE Term/whole policy Benefit amount Cash value (if applicable)

7 Financial History ES O Have you ever been involved in a bankruptcy? Have you owned a business by yourself or with others in the last six years? Do you have any business debts? Have you received any public benefits (social security, welfare, unemployment compensation, food stamps, etc. in the past two years? Have you ever been told you received more money from the government than you were supposed to (social security, welfare, unemployment compensation, food stamps, etc.)? Do you expect to receive any money or property in the near future by gift, inheritance or life insurance proceeds? Are you the beneficiary of a trust or other future interest? Have you made any payments to a single creditor (other than mortgage or car loan) totaling more than $600 in the last 90 days? Have you repaid any creditors in the last year who are friends or family? Have you been sued in the last year? Has any property been taken from you by legal process in the last year (wage garnishment, bank account levy, etc.)? Have you had any property foreclosed or repossessed during the past two years? Are you currently suing someone? Do you have any possible reason to sue someone for damage to your property or injuries to yourself or your family? Have you made any substantial sales or transfers of property within the last six years? Have you made any gifts or charitable contributions more than $200 to any recipient within the last year? Have you had your name on any bank account (savings, checking, CD) that was closed in the last year? Do you have a safe deposit box? Does anybody owe you any money or child support? Have you been ordered to pay child support? Other than a court order, do you pay to support anybody who doesn t live with you? Have you paid any person or agency for assistance with your debt?

8 Collection Defense Questions Optional One of the things that separates us from other bankruptcy lawyers is that we take the time to evaluate your situation to determine whether you are entitled to any money because one of your creditors broke the law. Take a few minutes to answer the following questions, and we ll use your answers to help us figure out whether we can make you some money. Has a debt collector called your friends, family, co-workers, or other third parties? Has a debt collector tried to collect a debt you don t owe? Has a debt collector called you names or said anything else that upset you? Has a debt collector done anything else you don t think was right? Please describe: Has a creditor or debt collector called you repeatedly? If so, how often? (ie. 3 times a day for 2 weeks): Do you believe that at least some of those calls were made with an autodialer? Did the creditor or collector leave automated voice messages? Have you ever worked with a debt settlement company before? Did they settle any of your debts? Did you pay them before they settled any of your debts? Have you had a vehicle repossessed? If so, did the repossession agent repossess when your payments were current? If so, did the repossession agent get the police involved? If so, did the repossession agent physically harm you? If so, did the repossession agent break into a locked garage? If so, did the repossession agent do anything else you didn t think was right? Please describe: Have you looked at your credit report recently? If so, are there any accounts on your credit report that you don t recognize? If so, is your name & social security number correct? If so, are there any addresses that you don t recognize? If so, are there any other errors on your credit report? Have you disputed these errors with the credit bureaus?

9 Taxes If Applicable Use this worksheet for any unfiled tax returns or balances due. Filed? Date filed Federal balance due State balance due 2012: 2011: 2010: 2009: Prior (specify year): Prior (specify year): Prior (specify year): Prior (specify year): Has any tax agency obtained a lien against you? es o

10 ACH Payment Plan Authorization Form Optional ou can pay off your balance through an automated payment plan. It s easy to set-up, and your payments will take care of themselves. Just complete and sign the form below to get started! Here s how the payment plan works: We decide upon a mutually agreeable payment schedule. ou authorize the regularly scheduled withdrawals from your checking or savings account. We will you a receipt documenting each payment as well as the total amount paid, the remaining balance and your next scheduled payment. When our full fee has been collected the authorization is canceled. Please complete the information below: TOTAL DUE: First payment amount: First payment date: Payment frequency (circle one): Monthly Bi-weekly Weekly Recurring payment amount: # of payments: I,, (full name) authorize Friedman Iverson, PLLC to charge my bank account, identified below, to pay off the above fees using installment payments in the amount and on the schedule indicated above. SIGATURE DATE I understand that this authorization will remain in effect until my balance is paid in full or I cancel it in writing, which ever comes first. I agree to notify Friedman Iverson in writing of any changes in my account information or termination of this authorization at least 15 days prior to the next billing date. If the above noted payment date falls on a weekend or holiday, I understand that the payment may be withdrawn on the next business day. I understand that because this is an electronic transaction, these funds may be withdrawn from my account as soon as the date identified above and monthly thereafter on the same date. In the case of an ACH Transaction being rejected for on Sufficient Funds (SF) I understand that Friedman Iverson, PLLC may, in its discretion, attempt to process the charge again within 30 days, and agree to pay an additional $35 charge for each attempt returned SF. This SF charge will be initiated as a separate transaction from the authorized recurring payment. I acknowledge that the origination of ACH transactions to my account must comply with the provisions of U.S. law. I will not dispute the company s recurring billing with my bank so long as the transaction corresponds to the terms indicated in this agreement.

11 ACH Payment Plan Authorization Form Optional Account Type: Checking Savings ame on Acct our Billing Address City, State, Zip Phone# Bank ame Account umber Bank Routing # Bank City/State