Bankruptcy Consultation Questionnaire — David M. Siegel & Associates

Spouse (if filing a joint petition)

Mr.Mrs.Ms.FirstMiddleLast

Other legal name(s) used in the last 6 years

Social Security NumberDate of BirthPlace of Birth

Contact Information

Home PhoneWork Phone

Cell PhoneCell Phone (2)

Email AddressEmail Address (2)

We respect your privacy and will only use your email for communication purposes. We will never sell or rent your email address or personal information with anyone.

Prior Bankruptcy Cases

NoneYesDate FiledDischarged / Dismissed OnCase NumberChapter

Additional case(s)

Confidential Bankruptcy Consultation Questionnaire · Page 1 of 12

ADDITIONAL REAL PROPERTY — listed on the continuation page (page 10)

Landlord / Tenant

NO LANDLORD or TENANT(S)or complete below for:TENANT(S)and/orLANDLORD

Name and Address

Term of LeaseMonthlyYearly

Expiration Date of Lease

ADDITIONAL TENANT(S) OR LANDLORD — listed on the continuation page (page 11)

Confidential Bankruptcy Consultation Questionnaire · Page 2 of 12

ADDITIONAL MOTOR VEHICLE(S) — listed on the continuation page (page 11)

Confidential Bankruptcy Consultation Questionnaire · Page 3 of 12

Property and Assets

Please disclose everything you have.

		Have it?	Fair Market Value
1.	Cash in Hand	YesNo	$
2.	Checking Account	YesNo	$
3.	Savings Account	YesNo	$
4.	Security Deposit (i.e. one month's rent with landlord)	YesNo	$
5.	Household Goods (TV, audio, furniture, etc.)	YesNo	$
6.	Antiques, Valuable Books, Valuable Collections	YesNo	$
7.	Normal Clothing and Jewelry	YesNo	$
8.	Furs, Expensive Clothing and Jewelry	YesNo	$
9.	Firearms (guns); Expensive Equipment (sports, hobby)	YesNo	$
10.	Term Life Insurance Policies (no cash value / cannot borrow)	YesNo	$
11.	Whole Life Insurance Policies (cash value / can borrow against)	YesNo	$
	Retirement and Financial Accounts — ERISA qualified or exempt?
12.	Annuities	YesNo	$
13.	Education I.R.A. / State Tuition Plan	YesNo	$
14.	I.R.A., Keogh, Profit Sharing	YesNo	$
15.	401(k)	YesNo	$
16.	Deferred Comp. / E.S.O.P. / Other	YesNo	$
	Any other financial accounts?
17.	Stocks (ownership of business)	YesNo	$
18.	Interests in Ventures or Partnerships	YesNo	$
19.	Government or Corporate Bonds	YesNo	$
20.	Accounts Receivable	YesNo	$
21.	Alimony, Maintenance or Support	YesNo	$
22.	Tax Refunds Expected	YesNo	$
23.	Inheritance Expected (within 6 months)	YesNo	$
24.	Lawsuits or Claims, current or potential (injury and/or workers comp. included)	YesNo	$
25.	Boats	YesNo	$
26.	Animals	YesNo	$
27.	Other assets or valuables? Trailer or RV? Money owed to you? Someone else's property in your name?	YesNo	$
28.	Crypto Currency	YesNo	$
29.	Storage Unit	YesNo
	NameContentsMarket Value$

Confidential Bankruptcy Consultation Questionnaire · Page 4 of 12

Employment Information

Name of Employer

Job Title

Working there how long?

Employer Address — Number & Street

CityStateZip

Annual Income Rate$

Employment Information (Spouse)

Name of Employer

Job Title

Working there how long?

Employer Address — Number & Street

CityStateZip

Annual Income Rate$

Employment Information (Additional and/or Part-Time Job)

Name of Employer

Job Title

Working there how long?

Employer Address — Number & Street

CityStateZip

Annual Income Rate$

Confidential Bankruptcy Consultation Questionnaire · Page 5 of 12

Monthly Income

	Debtor	Spouse	Additional (specify)
Gross (Monthly)	$	$	$
Taxes & Social Security	$	$	$
Health Insurance	$	$	$
Union Dues	$	$	$
Pension / Retirement	$	$	$
Retirement Loans*	$	$	$
*Payoff Date
Other	$	$	$
Net Per Month	$	$	$

Debtor

Spouse

Additional (specify)

Gross (Monthly)

$

Taxes & Social Security

$

Health Insurance

$

Union Dues

$

Pension / Retirement

$

Retirement Loans*

$

*Payoff Date

Other

$

Net Per Month

$

Other income	Debtor	Spouse
Operation of a Business	$	$
Unemployment Benefits	$	$
Alimony / Support	$	$
Social Security	$	$
Pension / Retirement	$	$
Other	$	$
TOTAL MONTHLY INCOME	$	Net per month (all columns) plus other income

Other income

Debtor

Spouse

Source / specify

Operation of a Business

$

Unemployment Benefits

$

Alimony / Support

$

Social Security

$

Pension / Retirement

$

Other

$

TOTAL MONTHLY INCOME

$

Net per month (all columns) plus other income

Confidential Bankruptcy Consultation Questionnaire · Page 6 of 12

Monthly Expenses (average)

Housing

Rent

$

Home Mortgage

$

Day of the month due

Second Mortgage

$

Day of the month due

Property Tax

$

None — in mortgage pmt.

Homeowner's / Renter's Insurance

$

None — in mortgage pmt.

Home Repairs and Maintenance

$

Water & Sewer & Trash

$

Association Fees / Assessment

$

Utilities and Communication

Power (Electricity & Gas)

$

Telephone (home)

$

Telephone (cellular)

$

Cable Television

$

Internet Access

$

Personal Expenses

Food (groceries & restaurants)

$

Clothing

$

Laundry & Cleaning

$

Medical & Dental

$

Gasoline, Tolls, Mass Transit

$

Recreation

$

Charitable Contributions (documented)

$

Insurance

Health Insurance

$

Automobile Insurance

$

Life Insurance

$

Family Care

Support to Others

$

Child Care / Tuition

$

Installment Payments

Automobile Payment

$

Other Installment Payment

$

Non-Filing Spouse

Non-filing spouse's separate expenses, if applicable (not included in total)

$

TOTAL MONTHLY EXPENSES

$

Child Support, Maintenance, Alimony, etc.

CurrentBehindAmount behind$

Name of Recipient

Address

CityStateZip

Confidential Bankruptcy Consultation Questionnaire · Page 7 of 12

Summary of Financial Affairs

If the answer to any of the questions below is Yes, please answer to the best of your ability, including dates, amounts, etc.

Confidential Bankruptcy Consultation Questionnaire · Page 8 of 12

Co-Debtors

List anyone who co-signed for any of your debt and anyone whose debt you co-signed for.No co-debtor

Name & Address of Co-Debtor

Creditor

Collateral?

Name & Address of Second Co-Debtor

Creditor

Collateral?

Student Loans

List all student loans below. These are not dischargeable in Bankruptcy regardless of their age.

Creditor Name

Address — Number & Street

City & StateZip

Amount$Account #

Creditor Name

Address — Number & Street

City & StateZip

Amount$Account #

Income Tax Debts

List all income tax debts below. Specify whether the debt is for Federal (I.R.S.) or State tax.

Tax Owed To

Address — Number & Street

City & StateZip

Amount$Was a return filed?YesNo

Is a tax lien recorded?YesNo

Year(s) of Tax Debt

Tax Owed To

Address — Number & Street

City & StateZip

Amount$Was a return filed?YesNo

Is a tax lien recorded?YesNo

Year(s) of Tax Debt

Confidential Bankruptcy Consultation Questionnaire · Page 9 of 12

Additional Real Estate

Confidential Bankruptcy Consultation Questionnaire · Page 10 of 12

Additional Tenant Information

Name & Address

LeaseYearlyMonthlyExpires

Name & Address

LeaseYearlyMonthlyExpires

Name & Address

LeaseYearlyMonthlyExpires

Additional Motor Vehicles

Confidential Bankruptcy Consultation Questionnaire · Page 11 of 12

For Office Use Only

Initial Contact Attorney

Confidential Bankruptcy Consultation Questionnaire · Page 12 of 12

Client Information

Spouse (if filing a joint petition)

Contact Information

Prior Bankruptcy Cases

Real Estate

Landlord / Tenant

Motor Vehicle #1

Motor Vehicle #2

Motor Vehicle #3

Property and Assets

Description of Household

Employment Information

Employment Information (Spouse)

Employment Information (Additional and/or Part-Time Job)

Monthly Income

Monthly Expenses (average)

Summary of Financial Affairs

Co-Debtors

Student Loans

Income Tax Debts

Additional Real Estate

Property #2

Property #3

Additional Tenant Information

Additional Motor Vehicles

Vehicle #4

Vehicle #5

For Office Use Only