CLIENT INFORMATIONDebtor (Always the Husband when filing jointly)Last I First I MiddleName: Name: Name:

Home: ( ) IWork: ( ) I Cell: ( )

Social Security Number: IHave you used any other names in the past eight years? I 0 No o Yes; If yes, please list:

Street Address:

City: I State: IZip: ICounty:

Email Address: ICo-Debtor (Always the Wife when filing jointly)Last I First IMiddleName: Name: Name:

Home: ( ) IWork: ( ) ICell: ( )

Social Security Number: IHave you used any other names in the past eight years? I 0 No o Yes; If yes, please list:

Address (if different from spouse):

I List information for all prior cases below."

Have you filed bankru tcy before? o No DYesc,

State Where Filed", If married, who was a party (Husband, Wife or Both)Prior Case Number Date Filed Did You Receive a Discharge?

Prior/Pending Bankruptcy Cases

Do you have domestic support obligations? I 0 No DYes If so, ple~se list' all such obligations below (whether current or not):

TYPE OF OBLIGATION WHO OWES? PAYMENT NAME & ADDRESS OF RECIPIENT

ChildSupport: o Debtor (Husband, if married)

o No DYes o Co-Debtor (Wife, if married) $ /month

Domestic Support Obligations

Unexpired Leases and ContractsList residential car & other leases and service or business contracts Provide copies of the leases and contracts 0 None, ,Nature and Description of Contract Name and Address of Other Party(ies) Date that Contract Expires Intention

, ' ' " " ,,""

DNoneDAssume (keep)DReject (cancel)

Information Regarding Your Residence (include other properties on separate page)DSame as Debtor Address: Name(s) on Title:

Street Address (if different from mailing address):

City: State: I Zip:Name of Primary Mortgage Company: Name of Second Mortgage Company (or Home Equity

Line of Credit):CI NoneMonthly Payment: $Is this payment current?

Monthly Payment: $ ClVes ClNo If not, how far behind are the payments?No. of Months: Dollar Amount $

Does Payment Include Taxes?Is this property in foreclosure?ClVes ClNo If not, how much are your yearly taxes? $ClVes ClNo

Does Payment Include Insurance?ClVes ClNo If not, how much is your annual premium? $ If so, has a sale date been set?

Is this payment current? Clves ClNo ClVes; Date:

If not, how far behind? Months: Dollar Amount $ ClNo

Name of Condo or Homeowners' Association: What are your intentions regarding thisCI None Property?

Monthly Payment: $ o Retain -- Keep Property and Continue to Pay Mortgage(s)Is this payment current?ClVes ClNo If not, how far behind are the payments? o Surrender -- Give up Property, and Stop Paying Mortgage(s)

No. of Months: Dollar Amount $

What is the current fair market value of the property? $

What do you base this estimation on?

Vehicle Information(include additional vehicles on separate sheet). List all vehicles, including

motorcycles, boats, RVs,etc, even if no money is owed on the vehicle.o None 0 More on Other Page

Vear: I Make: Model: Mileage:

Creditor Monthly No. of PaymentsName: Payment Amount: Left:CI Not Applicable CI Not Applicable CI Not Applicable

Vehicle Condition Intentions Name(s) on Title: ClDebtor aCo-Debtor

I:lExcellent I:lGood I:lFair I:lPoor I:l Retain (Keep) I:l Surrender ClOther:

Vear: I Make: Model: Mileage:

Creditor Monthly No. of PaymentsName: Payment Amount: Left:CI Not Applicable CI Not Applicable CI Not Applicable

Vehicle Condition Intentions Name(s) on Title: ClDebtor ClCo-Debtor

I:lExcellent I:lGood I:lFair I:lPoor I:l Retain (Keep) I:l Surrender ClOther:

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Personal PropertyPlease keep in mind, that al/ values given should be an estimate of what you think your

property could be sold for at a pawn shop or at a garage sale. Do not list what thereplacement value would be or what the purchase price was.

1-4ndividualH-Husband'

Please W-Wife-Catenorv of Propertv Mark Brief Description J- Joint Value/Amount

1. Cash on Hand? CJN/A $

2. Depository Accou nts. including checking, savings,CJN/A $

stocks or other. List all accounts, including the name of the institution,and state whether it is a checking, savings or other type of account.

(a)

(b)

(c)

(d)

3. Security deposits held by utility companies, landlord,CJN/A $

etc.

4. Household goods and furniture; includingCJN/A $

audio, video, and computer equipment. For value, please list whatyou believe your household goods and furniture could be sold for at agarage sale or to a pawn shop.

5. Books, pictures, art, records/cds and CJN/A $collectibles.6. Clothing. CJN/A $Value of clothing if sold at garage sale or to pawn shop.

7. Furs and jewelry CJN/A $

8. Sports, photographic, hobby CJN/A $equipment, firearms.

9. List all interests in insurance policies, and specifyCJN/A $

whether the policy is whole life or term. If whole life, list the cash value

(as opposed to the death value) of the policy. Please providelast statement from each account.10. An nuities. Please provide last statement from each

CJN/A $account.12. Interests in retirement accounts, including CJN/A $traditional IRAs, Roth IRA, 401 ks, andprofit sharing plans.Please erovide last statement from each account.

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1- IndividualH- Husband'" ,..

,,", Please W-WifeCategorY of Property ,.

.' " Marl< BrieiOescriptiCln "{ J-~oint ii'. . V"hle/A!11O\lnt13. List all interests in ON/A PleasecompleteClientInformation $any corporations or limited liability SheetSupplemental.

companies (LLCs) owned by you inwhole or in part.State the percentage of the business owned by you, and describe thenature and value of the business.14. List all interests in any ON/A PleasecompleteClientInformation $sole proprietorships, partnerships, joint SheetSupplemental.

ventures, or other businesses.State the percentage of the business owned by you, and describe thenature of the business.

15. Bonds. Please provide last statement from each account. ON/A $

16. Accounts receivable. ON/A $Describe all money that is owed to you; including any pending orpotential claims/lawsuits that you may have against others forpersonal injury, property damage or other reason.

17. Alimony/family support to which you ON/A $are entitled.18. Other liquidated debts owed to you, ON/A $including tax refundsto which you are entitled (even if not yet received).

19. Equitable or future interests or life estates; ON/A $lncludinq any inheritances to which you are entitled.

Interests in estate of decedent or life ON/A $20.

insurance plan or trust.Other contingent! unliquidated claims, ON/A $21.

including judgments owed to you.22. Boats, motorcycles, trailers, ON/A $

campers, and other vehiclesnot already listed.

23. Tools, office equipment, supplies, inventory (please specify).ON/A $

24. Other personal property not listed above ON/A $(including farm equipment, animals, aircraft, crops, copyrights,patents, trademarks, inventory, accounts receivable, educational IRAs,iicenses, franchises, etc.)

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Family Information

Marital Status"~List all dependents (please list additional dependents on separate sheet): [J NoneN A Ria" bi( dd it )ames oe e tions IP example: son, oran auai ter

o Singleo Marriedo Separatedo Divorcedo Widowed

Employment Information

City: Zip:

DNot Employed

(If unemployed or retiredplease indicat,~ lengtl1 of,time):

Debtor's PrimaryEmployer:

DNot Employed Co-Debtor's or Spouse's Primary Employer(even if spouse is not filing):

Address for each Employer: Address for each Employer:

State: City: Zip:State:

JobTitle:

(If unemployed or retiredplease indicate length of time):

StartDate:

JobTitle:

StartDate:

DSocial Security Income: $ _

DUnemployment

DWorker Compensation

DDisability

DAlimony/Chiid Support

o Pension/Retirement /Annuity

o Rental Income

o Other

DSocial Security Income: $ _

DUnemployment

DWorker Compensation

oDisability

DAlimony/Chiid Support

o Pension/Retirement /Annuity

o Rental Income

o Other

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Monthly Expenses

(Indicate how much you pay per item each month on average)

1. Rent (mortgage payments, if any, should be listedon page two)

s Renter's Insurance s

2. Utilities (list below) s Life insurance not deducted from paycheck $

. Home Telephone s

'Disabtliry and/or long-term care insrrrance not d~uctedfrom paycheck -

Health insurance that is not deducted from paycheck

sGas & Electric

s

Cell Phone s Auto insurance s

Garbage s Other insurance (specify): s

Internet (not included above) 12. 'Property taxes andior other taxes that are not deducted from - $your paycheck or included in your mortgage payment (specify):

Cable/Satellite (not included above): s 13. Installment payments for secured debts (other than your carsand mortgage) such as furniture, electronics, etc. (specify):

14. Afunony, maintenance and support that is ~ deductedfrom., $paycheck (specify): " -

s

-,3:· Hollie mauttenaJl~e,inclndip.grepairs andupkeep

4. Food $ 15. Payment for support of dependents not living with you s

5. Clothing s 16. Personal grooming, haircuts, etc. s

6. Laundry and dry cleaning s 17. Student Loan Payments $

7. '" Medical and dental expenses that are not coveredby insurance

8. Transportation, including gas and vehiclemaintenance (not including car payments)

$ 18. EducationCoi~ph)'sicany or ~entanychaHenged cMd(ren) s

$ 19. Childcare Expenses (daycare, babysitting) $

9. Recreation, entertainment, newspapers,~gazines,

$ 20. Care Corelderly, chronic3n;v ill, or disabled family-members .

10. Charitable contributions s 21. Education expenses for your children under 18 $

Home Insurance not included in mortgage $

22. Non-mandatory contributions to retirement accounts that are. $not deducted from your paycheck .'

23. Other expenses not listed above (not including expenses thatwill be included in your bankruptcy)

11. Insurance Payments (list below)

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Form 7: Statement of Financial Affairs

1. Payments to creditors.(a) List all payments made to creditors that total more than $600 per creditor made within the last 90 days.

Name and Address of Creditor Dates of Payments Amount paid Amount still owed

o NONE

I I(b) List all payments (regardless of amount) made within the last twelve months to relatives, business partners and their relatives, and toany corporations or other busine~s entities that are owned (in whole or in part) by you., your relatives, business partners and affiliates).

Name, Address & Relationship of Creditor Dates of Pavments Amount Paid Amount Still Owedo NONE

2. Lawsuits, executions, garnishments and attachments.(a) . List all lawsuits and administrative proceedings to which you are or were a party within the last twelve months. Provide copes of allpaperwork relating to said proceedings and state whether a judgment has been entered or if the case is still.pending ..

(b) Describe all property that has been garnished, seized, or attached by way of a lien or otherwise, during the past twelve months.

3. Repossessions, foreclosures, and returns.List all property that has been repossessed by a creditor, sold at a foreclosure sale, or transferred through a deed in lieu of foreclosure,within the last twelve months.

Name and Address of Creditor Date of Repossession or Other Action Description and Value of Property

4. Assignments and receiverships.(a) Describe any property that was transferred to any of your creditors as payment (in whole or in part) for a debt within the last 120 days.

Name .andAddress of Assignee Date of Assignment Terms of Assignment/Settlement

o NONE

I(b) List all property which has been in the hands of a custodian, receiver, or court-appointed official within the last twelve months.

Name and Address of Custodian Case Caption & Number Date of Order Description and Value of Property

o NONE

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5. Giftsand Charitable Contributions.

o NONE

6. Losses. List all losses from fire, theft, gambling or other casualty within the last twelve months.

Descri tion and Value of Pro ertv Circwnstances and Amount Covered by Insurance if An Date of Losso NONE

7. Payments related to debt 'counselingor bankruptcy.List all payments made within the last twelve months for debt consultation, consolidation and/or bankruptcy (other than those paid toKeenan Law Offices). .

Name and Address of Payeeo NONE

Name of Person Who Paid, if Not You Amount Paid

8. Other transfers (includingsale of your property).(a) List all other property, other than property transferred in your ordinary course of business, transferred either absolutely or as security,within the last twenty-four months. This should include the sale or gift of any real estate, cars, motorcycles, boats and other itemsregardless of price. Provide copies of all closing statements, bills of sale, and/or other documents describing same.

o NONE

(b) List all property that you transferred into a trust of which you are a trustee or beneficiary within the lastten years.

Name of Trust or Similar Device Date of Transfer Amount of Money or Desert tion and Value of Pro ertv or Interesto NONE

9. Closedfinancial accounts.List all bank accounts and other fmancial accounts and instruments held in your name or for your benefit which were closed, sold, orotherwise transferred within the last twelve months.

Name and Address of Institution Type and Number of Account & Final Balance Amount and Date of Sale or Closing

o NONE

10. Safe deposit boxes.List each safe deposit or other box or depository in which you have or have h~d securities, cash, or other valuables within the last twelvemonths.

Name and Address of Institution Name and Address of Those With Access Contents Date of Transfer if Ano NONE

PageS

11. Setoffs.List W1 setoffs made by any creditor, including a bank, against a debt or deposit of yours within the last 90 days.

Name and Address of Creditor Date of Setoff Amount of Setoffo NONE

12. Property held for another person.List all property that y~u holdor control that is owned by another person.

Name and Address of Owner Descri tion and Value of Pro ertv Location of Pro erto NONE

13. Prior address(es). lfyou have moved within the last three years, list all previous addresses.

Address Your Name at the Time Dates of Occu ancvo NONE

14. Spousesand Former Spouses. lfyou resided in a community property state, cOmmonwealth, or territol)''(including Alaska, Arizona, California, Idaho, Louisiana, Nevada, New Mexico, Puerto Rico, Texas, Washington, or Wisconsin) within. the last eight years, identify the name of your spouse/former spouse who resided with you in the community property state.

o NONE

IIWE declare under penalty of perjury the information provided on this form is true and correct to the best of my/our knowledge.

Debtor Date Co-Debtor Date

UnsecUI·edDebts (Not Included on Credit Report)

It is your obligation to make sure all of your debts are listed on the bankruptcy petition. H any debt is not listed on your credit report,please provide the last statement/correspondence from the creditor, or provide information for it below and/or on a separate page.PLEASE PROVIDE COPIES OF MAIL RECEIVED FROM CREDITORS IN THE LAST 60 DAYS.

o Debtor (Husband) Creditor Account

o Co-Debtor (Wife) Name: No:

o Joint

Date Date Last I AccountI Name of Collection Agency

Or Co-signer's NameOpened: Used: Balance: And Address:OTaxes· OStudent Loan OCredit Card Oother Unsecured Loarr OMedical Oother:

o Debtor (Husband) Creditor Account

o Co-Debtor (Wife) Name: No:

o Joint

Date Date Last IAccountI Nameof Collection Agency

Or Co-signer's NameOpened: Used: Balance: And Address:

OT~xes OStudent Loan OCredit Card Oother Unsecured Loan OMedical Oother:

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