Arizona s leader in legal document preparation since Chapter 7 Bankruptcy Questionnaire

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1 Arizona s leader in legal document preparation since Chapter 7 Bankruptcy Questionnaire North 19 th Ave., Phoenix, AZ Off Fax. DiscountDivorce@msn.com DiscountDivorceAZ.com Rev. 25 November

2 Instructions How to complete this questionnaire 1. Please print legibly; staff must be able to read this document to accurately complete your documents. 2. Should you need additional space please make extra copies of this questionnaire and attach additional pages as needed. 3. Please do not send or bring us your creditor statements. We cannot read the statements for you. 4. Please make a list of all creditors that you owe. The list must contain the name of the company, complete mailing address and approximate payoff amount. You may also complete this list on our website at: (Atlernatively you can bring us a credit report with this information.) 5. As you complete this questionnaire if you have questions please call our office we would be happy to help you. Make an Office Appointment After completing the questionnaire and making or obtaining a list of creditors that you owe please contact the office for an appointment Office Phone: Fax: Monday thru Thursday 9:00 am 12:30pm 1:30pm 5:00pm and Friday 9:00 am 12:30pm Saturday and Sunday Closed Office location: North 19 th Ave., Phoenix, AZ (Northeast corner of Thunderbird Rd. & 19 th Ave., Subway s parking lot) What to Bring to Your Appointment When you meet with us please bring the following items. 1. A completed questionnaire. 2. A copy of any law suits you have been served with. 3. A photo ID, such as a driver s license or state issued ID. 4. A list of creditors that you owe or a copy of your credit report. 5. Payment: 199. NO PERSONAL CHECKS will be accepted.6. If you own a business (are a shareholder/partner/are on the board of directors/etc), have made payments for credit counseling, filed prior bankruptcy, paid an attorney, or any other unusual situation please inform us at the time of your appointment. The Court Will Require the Following: After your bankruptcy documents have been prepared by us the court will require all of the following items at the time of the initial filing. 1. Photo ID. 2. Social Security Card. 3. Two (2) months of pay stubs. 4. Money order or cash for filing fee. Current filing fee is 335. The court does offer a waiver or deferral (payment) plan on this fee. The court makes all determination regarding eligablity in all cases. 5. Credit Counseling Certificate. The Court is located at 230 North First Avenue, 1st Floor, Phoenix, AZ (Van Buren & 1st Ave.) There is all day parking for 2.50 just North of Van Buren on 1st Ave. on the East side of 1st Ave Please keep this page as reference. For legal advice we recommend calling the Arizona Bar Assoc. Attorney Referral Service at or 2

3 How to Obtain a Credit Report If you do not know who all of your creditors are, we recommend bringing in a copy of your credit report. You may use whatever service you wish to obtain a credit report but we require that the following information be on the credit report: 1. Name of each creditor; 2. of each creditor; and 3. An approximate balance owed. We recommend using Advantage Plus Credit Reporting, Inc., 7998 West Thunderbird Road, Ste. 109, Peoria, AZ Hours: Monday-Friday 8:00-5:00 MST Phone: Website: Pete@advpluscredit.com Advantage Plus Credit Reporting, Inc. charges 25 for a credit report without scores Alternatively you can complete this form on our internet site at: Please keep this page as reference. 3

4 Part 1 Name Con Intv Doc Prep Chapter 7 Bankruptcy-Personal / Non-Business for 2016 Bankruptcy Filings Personal Information An Arizona Legal Document Company Discount Divorce & Bankruptcy PO Box Phoenix, AZ Office Fax DiscountDivorce@msn.com First M.I. Last Street City State ZIP Date of Birth (MM/DD/YYYY) Social Security No. Cell Phone Name Spouse s information if filing jointly First M.I. Last Street City State ZIP Date of Birth (MM/DD/YYYY) Social Security No. Cell Phone 4

5 Part 2 Income Test Elilgabitity What has been your average monthly income for the past six months from all income sources? If filing jointly, what has been your spouse s average monthly income for the past six months from all income sources? How many dependents do you support? Do all of these dependents reside with you? If yes, are any of these dependents eighteen years of age or older? If yes, do you claim all these dependents on your taxes? Marital Status (Check only one) Unmarried (Single) Married not filing jointly and declaring you and your spouse are not living together Married not filing jointly and you and your spouse are living together Married filing jointly Prior Filing and Consulting Have you filed for a Chapter 7 bankruptcy in the past 8 years? Have resided in Arizona for the past 180 days Have you consulted with an attorney regarding bankruptcy? ONLY -- Do Not Complet This Part. Go to Part 3 Family Size Debtor 1 Avg. Monthly Income Debtor 2 Avg. Monthly Income How much income is from Social Securty SSI or SSD? Total + - = Means Test As of 11/2015 Total x 12 Does income exceed current means test? = 1 Earner People People People People People People People

6 Part 3 Real Property Property, Real Do you own your home or are you renting? Own Renting Other If you own where is it located? If you do not own property go to Part 4 City, State and ZIP What is the current market value? What is it? Do you own other Real Estate? If yes, where is it located? Single-family home Duplex or multi-unit building Condominium or cooperative Manufactured or mobile home Land Investment property Timeshare Other City, State and ZIP What is the current market value? What is it? Do you own other Real Estate? If yes, please use additional paper to describe. Single-family home Duplex or multi-unit building Condominium or cooperative Manufactured or mobile home Land Investment property Timeshare Other 6

7 Part 4 Vehicles Property, Personal Do you own or lease any cars, vans, trucks, tractors, sport utility vehicles, motorcycles? If yes, describe: Make Model Year Current market value Vehicles (cont.) Appoximate Mileage Do you own or lease any other cars, vans, trucks, tractors, sport utility vehicles, motorcycles? (8) 6000 / If yes, describe: Make Model Year Appoximate Mileage Current market value Vehicles (cont.) Other Vehicles Do you own or lease any other cars, vans, trucks, tractors, sport utility vehicles, motorcycles? If yes, please use additional paper to describe. Do you own or lease any watercraft, aircraft, motor homes, ATVs and other recreational vehicles, other vehicles, and accessories? If yes, describe: Make Model Year Appoximate Mileage Current market value Other Vehicles (cont.) Do you own or lease any other watercraft, aircraft, motor homes, ATVs and other recreational vehicles, other vehicles, and accessories? If yes, please use additional paper to describe. 7

8 Part 4 (cont.) Household Property, Personal Do you own any major appliances, furniture, linens, china, kitchenware? Describe Market Value? Electronics Do you own any Televisions and radios; audio, video, stereo, and digital equipment; computers, printers, scanners; music collections; electronic devices including cell phones, cameras, media players, games Describe Market Value? Collectiables Antiques and figurines; paintings, prints, or other artwork; books, pictures, or other art objects; stamp, coin, or baseball card collections; other collections, memorabilia, collectibles Describe Market Value? None Equipment for Sports & Hobbies Sports, photographic, exercise, and other hobby equipment; bicycles, pool tables, golf clubs, skis; canoes and kayaks; carpentry tools; musical instruments Describe Market Value? (2) 400 Firearms Pistols, rifles, shotguns, ammunition, and related equipment (7) 1000 Describe Market Value? Clothing Everyday clothes, furs, leather coats, designer wear, shoes, accessories (1) 500 Describe Market Value? Jewlery Everyday jewelry, costume jewelry, engagement rings, wedding rings, heirloom jewelry, watches, gems, gold, silver Describe Market Value? (4) 2000 (wedding rings) (6) 150 (watch) Non-Farm Animals Dogs, cats, birds, horses (3) 500 Describe Market Value? 8

9 Part 4 (cont.) Financail Accounts Property, Personal Do you have a checking, savings, or other financial accounts; certificates of deposit; shares in credit unions, brokerage houses, and other similar institutions? If yes, list each (A)(9) 300 / 600 Name of bank or other institution Name of bank or other institution Name of bank or other institution Name of bank or other institution Name of bank or other institution Current Value Current Value Current Value Current Value Current Value Bonds, Mutal Funds, Publicly Traded Stocks Do you have any bond funds, investment accounts with brokerage firms, money market accounts? If yes, list each. None Name of institution or issuer Name of institution or issuer Name of institution or issuer Current Value Current Value Current Value Retirement and Pension Accounts Do you have an interests in IRA, ERISA, Keogh, 401(k), 403(b), thrift savings accounts, or other pension or profit-sharing plans? If yes, list each AZ Retirement (B) Others (C) IRA Police Fire Name of institution Type of Account Current Value Name of institution Type of Account Current Value Security Deposits Name of institution or Type of Account Your share of all unused deposits you have made so that you may continue service or use from a company. Examples: Agreements with landlords, prepaid rent, public utilities (electric, gas, water), telecommunications companies, or others Current Value (C) 2000 Residents Name of institution or individuals name Name of institution or individuals name Name of institution or individuals name Deposit Type (ie gas, rent,etc) Deposit Type (ie gas, rent,etc) Deposit Type (ie gas, rent,etc) Amount Amount Amount 9

10 Part 4 (cont.) Tax Refunds Property, Personal Are currently expecting a tax refund? None Business State Amount expecting Federal Amount expecting Other Amount expecting Do you own any intest in any business? If no, got to Part 5 Do you have any accounts receivable or commissions already earned? Do you have Business-related computers, software, modems, printers, copiers, fax machines, rugs, telephones, desks, chairs, electronic devices Do you have any Intestes in a partnership of joint venture? If yes, describe: If yes, describe: If yes, what is the name of the entity and your percentage of ownership? Only Total real estate Total Vehicle + Total Personal and Household + Total Finacial Assets + Total Business + Total Presonal Property = Total of Personal and Real Property 10

11 Part 5 Secured Claims Do you have a mortgage? If yes, who is the lender? Name of Lender How much is owed? of Lender City, State and ZIP What is your intention Surrender property Keep property Street of Property. City, State and ZIP of Property Do you have a car payment? If yes, who is the lender? Name of Lender How much is owed? of Lender City, State and ZIP Year, Make and Model of Vehicle Do you have another car payment? If yes, who is the lender? What is your intention Surrender property Keep property Name of Lender How much is owed? of Lender City, State and ZIP Year, Make and Model of Vehicle What is your intention Surrender property Keep property If you have additional mortgages or vehicle loans please use additional paper. 11

12 Part 6 Unexpired Leases Do you any unexpired leases? If no, go to Part 7 List separately each person or company with whom you have the contract or lease. Then state what each contract or lease is for (for example, rent, vehicle lease, cell phone). State what the contract or lease is for Name of Company or Individual State what the contract or lease is for Name of Company or Individual Part 7 Use additional paper if there are more contracts and leases Co-Debtors Are there any Co-Debtors? If no, go to Part 8 Within the last 8 years, were you married and did you live in a community property state or territory? (Community property states and territories include Arizona, California, Idaho, Louisiana, Nevada, New Mexico, Puerto Rico, Texas, Washington, and Wisconsin.) If yes, Name of Spouse List all of your codebtors. Do not include your spouse as a codebtor if your spouse is filing with you. Name of Co-Debtor Name of Creditor that you and the Co-Debtor Owe Name of Co-Debtor Name of Creditor that you and the Co-Debtor Owe 12

13 Part 8 Income and Employment You. 1. Are you employed? If filing jointly or your spouse is living with you and your not filing jointly. Is your spouse employed? Occupation Name of Employer City State and ZIP How long employed there? Occupation Name of Employer City State and ZIP How long employed there? You Spouse 2. List monthly gross wages, salary, and commissions 3. Estimate and list monthly overtime pay. 4. Total Income (Add line 2 and 3) 5. Payroll Deductions 5a. Tax, Medicare, and Social Security Deductions 5b. Mandatory contributions for retirement plans 5c. Voluntary contributions for retirement plans 5d. Required repayments of retirement loans 5e. Insurance 5f. Domestic Support Obligations 5g. Union Dues 5h. Other Deductions 6. Total Deductions Add lines 5a though 5h 7. Take Home Pay. Subtract Line 6 from Line 4 13

14 8. Other Income (Part 8 cont.) You Spouse 8a. Net Income from rental property or from operating a business. 8b. Interest and dividends 8c. Family support payments (alimony, child support, etc) 8d. Unemployment compensations 8e. Social Security 8f. Other government assistance 8g. Pensions or retirement income 8h. All other monthly income 9. Total Other Income Add Lines 8a through 8h. 10. Calculate montly income Add line 7 and 9 10a. 10b. Total Add line 10a and 10b 11. State all other regular contributions to the expenses that you list. (ie. Include contributions from an unmarried partner, members of your household, your dependents, your roommates, and other friends or relatives.) 12. Total Add line 10 and 11. Do you expect an increase or decrease within the next year? 14

15 Part 9 Dependant Information Is this a joint case? If yes, does your spouse live in a separate household? Do you have dependants? If yes, complete the information below for each child: Son Daughter Age Does this child live with you? Son Daughter Age Does this child live with you? Son Daughter Age Does this child live with you? Son Daughter Age Does this child live with you? Son Daughter Age Does this child live with you? Son Daughter Age Does this child live with you? Part 10 Expenses 1. The rental or home ownership expenses for your residence. Include first mortgage payments and any rent for 1 the ground or lot. 1a. Real estate taxes 1a 1b. Property, homeowner s, or renter s insurance 1b 1c. Home maintenance, repair, and upkeep expenses 1c 1d. Homeowner s association or condominium dues 1d 2. Additional mortgage payments for your residence, such as home equity loans 2 3. Utilities: 3a. Electricity, heat, natural gas 3a 3b. Water, sewer, garbage collection 3b 3c. Telephone, cell phone, Internet, satellite, and cable services 3c 3d. Other. Specify: 3d 4. Food and housekeeping supplies 4 5. Childcare and children s education costs 5 6. Clothing, laundry, and dry cleaning 6 7. Personal care products and services 7 8. Medical and dental expenses 8 9. Transportation. Include gas, maintenance, bus or train fare. 9 Do not include car payments. 10. Entertainment, clubs, recreation, newspapers, magazines, and books 10 15

16 Part 10 (cont) Expenses 11. Charitable contributions and religious donations Insurance. Not deducted from payroll 12a. Life insurance 12a 12b. Health insurance 12b 12c. Vehicle insurance 12c 12d. Other insurance. Specify: 12d 13. Taxes. 13 Not deducted from payroll 14. Installment or lease payments: 14a. Car payments for Vehicle 1 14a 14b. Car payments for Vehicle 2 14b 14c. Other. Specify: 14c 14d. Other. Specify: 14d 15. Your payments of alimony, maintenance, and support that you did not report as deducted in Part Other payments you make to support others who do not live with you. Specify Other real property expenses not included in Part 8 17a. Mortgages on other property 17a 17b. Real estate taxes 17b 17c. Property, homeowner s, or renter s insurance 17c 17d. Maintenance, repair, and upkeep expenses 17d 17e. Homeowner s association or condominium dues 17e 18. Other. Specify: Calculate your monthly expenses. Add lines 1 through Calculate your monthly net income. 20a. Copy line 12 from Part 8 (monthly income) 20a 20b. Copy your monthly expenses from line 19 above. 20b 20c. Subtract your monthly expenses from your monthly income. The result is your monthly net income. 20c 21. Do you expect an increase or decrease in your expenses within the year after you file this form? For example, do you expect to finish paying for your car loan within the year or do you expect your mortgage payment to increase or decrease because of a modification to the terms of your mortgage? No Yes, explain: If you and your spouse are not living together but are filing jointly copy and complete a separate Part 10 for them. 16

17 Part 11 Your Financial Affiars 1. During the last 3 years, have you lived anywhere other than where you live now? If yes, complete the following below: From: Until: From: Until: From: Until: 2. Income from employement or operation of a business You Spouse Gross year to date income? Last year s gross annual income? Pervious year s gross annual income? 3. Income from other sources You Spouse Alimony; child support; Social Security, unemployment, and other public benefit payments; pensions; rental income; interest; dividends; money collected from lawsuits; royalties; and gambling and lottery winnings. Year to date income? Last year s income? Pervious year s income? 4. Have you paid any creditors 600 or more? If yes, complete the following below: What was the payment for Name of Creditor Amount Paid Car Credit card Amount Still Owed Loan repayment Suppliers or vendors Other What was the payment for Name of Creditor Amount Paid Car Credit card Amount Still Owed Loan repayment Suppliers or vendors Other 17

18 Part 11 (cont) Your Financial Affiars 5. Within 1 year were you a party in any lawsuit, court action, or administrative proceeding? If yes, please attach copy of lawsuit 6. Within 1 year was any of your property repossessed, foreclosed, garnished, attached, seized, or levied? If yes, please explain. Description of Property Name of creditor Date Value of property 7. Within 1 year did you close any bank accounts If yes, please explain. Name of Bank or Institution City State and ZIP Type of Account Checking Savings Money market Brokerage Other Last Balance Date of closing Last 4 digits of account 8. Within the last 4 years did you own a business? If yes, what type of business: A sole proprietor or self-employed in a trade, profession, or other activity, either full-time or part-time A member of a limited liability company (LLC) or limited liability partnership (LLP) A partner in a partnership An officer, director, or managing executive of a corporation An owner of at least 5% of the voting or equity securities of a corporation Part 12 Have you gone by any other name in the past 8 years? (maiden name, etc.) If yes, what name? We never release any information about you or your case to anyone other than the Court or 3 rd parties that we contract to process your case (i.e. process servers, etc.) unless we are compelled by Court Order or with your permission. With that in mind is there anyone you want to authorize to call for information or pickup documents on your behalf? If yes, who? What relation are they to you? You certifiy that all information contained in this questionnaire is true and correct. x dd/mm/yyyy Stop Here 18

19 Only Do Not Write Total claim Total claims from Part 1 Domestic support obligations Taxes and certain other debts you owe the government Claims for death or personal injury while you were intoxicated Other. Add all other priority unsecured claims. Write that amount here. Total. Total claims from Part 2 Total claim Student loans Obligations arising out of a separation agreement or divorce that you did not report as priority claims Debts to pension or profit-sharing plans, and other similar debts Other. Add all other nonpriority unsecured claims. Write that amount here. Total. 19