BANKRUPTCY QUESTIONNAIRE Date of completing form: Year:_______ Month: FAMILY Name(s): Spouse: Soc. Sec. No.: Soc. Sec. No.: Address: Phone Numbers: List Children and ages: Employer: Spouse's: Address: Address: Job or Position: Spouse's: Previous addresses for last three years: Divorces: When Final: Case Number: BANKS Give name and addresses of bank(s) you use for the following: Checking Accounts: Savings Accounts: Do you have a safe deposit box: Circle Yes or No Where: What is kept in the box(es) As of today, how much do you have in your checking and savings accounts? Checking Accounts: Savings Accounts: CARS List the cars you own and fill in the information requested: (If more than two cars, use another sheet) Car 1. Model, make and year: Approx. value: $ If financed, name, address and account number of lender: If financed, approximate amount you now owe: $ Reaffirmation: Do you want to retain and continue to pay for this car after filing a bankruptcy, or do you want to return the car to the creditor and not pay for the car? Car 2. Model, make and year: Approx. value: $ If financed, name, address and account number of lender If financed, approximate amount you now owe: $ Reaffirmation: Do you want to retain and continue to pay for this car after filing a bankruptcy, or do you want to return the car to the creditor and not pay for the car? RESIDENCE Do you own a house: Circle One: Yes No If you own a house, when did you purchase it? What was the purchase price? What do you estimate as the current value? Who is your mortgage lender? Name: Address: Account No.: What is the current balance on your mortgage? If you are not current on your mortgage payments, how many payments behind are you? Do you have a second mortgage or a home equity loan? Circle Yes No For your second loan, please provide the following: Who is your lender? Name: Address: Account No.: What is the current balance on this loan? If you are not current on your payments, how many payments behind are you? INCOME TAX INFORMATION What tax refund, if any, did you receive from your last tax return? $ Are you currently waiting to receive any tax refund? Yes or No If Yes, indicate whether it is from a state or federal return, and state the amount of the refund expected: Federal or State $ Do you owe any taxes, other than for the current year? Yes or No If Yes, please provide information as to amounts owed, etc. Attach or bring notices, if possible. INCOME SOURCES What was your income from the following sources in the previous two years? Take the information from your last two years' tax returns. Husband Wife YEAR: Salary: Interest: Dividends: Sales of property: ASSETS List and value your property, using the following as a guide. In setting values, imagine the property was being sold at a garage sale. List type and number of rooms in home or apartment: (E.g., 3 bedrooms, LR, DR, etc.) Tools: Computer(s): Boats, motorcycles, other sporting goods: Jewelry: Televisions and Stereo: Stock, bonds, mutual fund shares (other than in retirement plans): Retirement plan funds: Include pension and profit-sharing accounts, as well as IRA accounts. (Generally, retirement plans are not touched in bankruptcy, but it is necessary to list them) Other assets: DEBTS It is necessary to list all debts, including debts to family members. We do not need to include the current amounts due to utilities, but utilities should be included if there are past due amounts that will not be paid before the case is filed. Enclose most recent statements from each creditor. If you do not have a statement, list creditor below or on a separate page: I cannot work from a credit report, as a report typically does not list address or account numbers. Information required for each creditors for which you do not have a statement: Name: Amount Owed Address: Account Number: State whether debt is based on a loan of money or a debt arising out goods or services. Does the creditor have a security interest in any property, such as a vehicle, furnishings, bank account, etc? If so, list the collateral or security for the loan. Other Attorneys Contacted: Name and address of other attorneys you have consulted in the past year, subject of consultation and amount paid, if anything (This information is required under the Bankruptcy Code) EXPENSE STATEMENT/BUDGET Estimate your average current expenditures, using the following list: I. Home-related expenses: a. Rent or home loan payment (including taxes and insurance, if part of payment): b. Assessment or maintenance fee: c: Utilities: Electricity Gas Water Cable Telephone Other (specify) d. Home maintenance (repairs and upkeep) II. Non-Home Expenses: a. Taxes: 1. Real Estate Taxes per year, if not included ____________ annually as part of your mortgage payment 2. Income tax payments on past years ____________ per month 3. Estimated tax payments for current year ____________ per quarter b. Alimony, maintenance, or support ____________ per month payments (not received) (attach additional sheet listing name, age, relationship of beneficiaries). c. Insurance (not deducted from wages and not included with mortgage payment) Amount Frequency (Per year, month, quarter, etc.) Life ________ Health ________ Auto ________ Homeowners/Renters ________ Other (specify type and amount) d. Installment payments: Auto (which one?) Is this a lease? If a lease, when did it start and when will it end? Do you plan to keep this car, or return it to the creditor or lease company? Auto (which one?) Is this a lease? If a lease, when did it start and when will it end? Do you plan to keep this car, or return it to the creditor or lease company? Other (specify company, type of collateral, if any, and amount) e. Transportation (not including Per month car installment payments) f. Education (including tuition and Per month school books for adults and children) Do any children attend a non-public school? Are any children going to college? g. Food Per month h. Clothing _________ Per month i. Medical, dental and medicines Per month j. Laundry and cleaning Per month k. Newspapers, periodicals, and books Per month l. Recreation, clubs and entertainment Per month m. Religious and Charitable contributions Per month n. Other regular expenses (specify) INCOME: Provide last two current pay stubs for each person. Other income? Interest: Dividends: Other Information and Documents: Documents to Bring or Provide to Gary Moore: ______ Any creditor bills ______ Copies or mortgage and car payment coupons ______ Divorce or Dissolution of Marriage Orders and Agreements ______ Copies of any contracts, loan agreements and other documents that might provide information about any of the questions raised above. ______ Automobile Lease ______ Most recent tax return ______ Summons, complaint, orders or other information regarding any lawsuits that have been filed against you Gary M. Moore Attorney at Law 535 South Washington Street Naperville, Illinois 60540 Phone: (630) 357-6966; Fax: (630) 357-1210 E-Mail Garymoore@Naperlaw.com