Questions 1-15 are to be completed by all debtors. Debtors that are or
have been in business, as defined below, also must complete Questions
16 -21. Each question must be answered. If the answer to any question
"None," or the question is not applicable, mark the box labeled
"None." If additional space is needed for the answer to any question,
use and attach a separate sheet properly identified with the case name,
case number (if known), and the number of the question.
Income from employment or operation of business
State the gross amount of income the debtor has received from
employment, trade, or profession, or from operation of the debtor's
business from the beginning of this calendar year to the date this case
was commenced. State also the gross amounts received during the two
years immediately preceding this calendar year. (A debtor that
maintains, or has maintained, financial records on the basis of a
fiscal rather than a calendar year may report fiscal year income.
Identify the beginning and ending dates of the debtor's fiscal year.)
If a joint petition is filed, state income for each spouse separately.
(Married debtors filing under chapter 12 or chapter 13 must state
income of both spouses whether or not a joint petition is filed, unless
the spouses are separated and a joint petition is not filed.)
AMOUNT SOURCE(if more than one)
Income other than from employment or operation of business
State the amount of income received by the debtor other than from
employment, trade, profession, or operation of the debtor's business
during the two years immediately preceding the commencement of this
case. Give particulars. If a joint petition is filed, state income for
each spouse separately. (Married debtors filing under chapter 12 or
chapter 13 must state income for each spouse whether or not a joint
petition is filed, unless the spouses are separated and a joint
petition is not filed.)
AMOUNT SOURCE
Payments to creditors
List all payments on loans, installment purchases of goods or
services, and other debts, aggregating more than $600 to any creditor,
made within 90 days immediately preceding the commencement of this
case. (Married debtors filing under chapter 12 or chapter 13 must
include payments by either or both spouses whether or not a joint
petition is filed, unless the spouses are separated and a joint
petition is not filed.)
DATES OF AMOUNT AMOUNT
NAME AND ADDRESS OF CREDITOR PAYMENTS PAID STILL OWING
List all payments made within one year immediately preceding the
commencement of this case to or for the benefit of creditors who are or
were insiders. (Married debtors filing under chapter 12 or chapter 13
must include payments by either or both spouses whether or not a joint
petition is filed, unless the spouses are separated and a joint
petition is not filed.)
NAME AND ADDRESS OF CREDITOR DATE OF AMOUNT AMOUNT
AND RELATIONSHIP TO DEBTOR PAYMENT PAID STILL OWING
Suits, executions, garnishments and attachments
List all suits to which the debtor is or was a party within one year
immediately preceding the filing of this bankruptcy case. (Married
debtors filing under chapter 12 or 13 must include information
concerning either or both spouses whether or not a joint petition is
filed, unless the spouses are separated and a joint petition is not
filed).
CAPTION OF SUIT NATURE OF COURT AND STATUS OR
AND CASE NUMBER PROCEEDING LOCATION DISPOSITION
Describe all property that has been attached, garnished or seized under
any legal or equitable process within one year immediately preceding
the commencement of this case. (Married debtors filing under chapter
12 or chapter 13 must include information concerning property of either
or both spouses whether or not a joint petition is filed, unless the
spouses are separated and a joint petition is not filed.)
NAME AND ADDRESS DESCRIPTION
OF PERSON FOR WHOSE DATE OF AND VALUE OF
BENEFIT PROPERTY WAS SEIZED SEIZURE PROPERTY
Repossessions, foreclosures and returns
List all property that has been repossessed by a creditor, sold at a
foreclosure sale, transferred through a deed in lieu of foreclosure or
returned to the seller, within one year immediately preceding the
commencement of this case. (Married debtors filing under chapter 12 or
chapter 13 must include information concerning property of either or
both spouses whether or not a joint petition is filed, unless the
spouses are separated and a joint petition is not filed.)
DATE OF REPOSSESSION, DESCRIPTION
NAME AND ADDRESS FORECLOSURE SALE, AND VALUE OF
OF CREDITOR OR SELLER TRANSFER OR RETURN PROPERTY
Assignments and receiverships
a. Describe any assignment of property for the benefit of creditors
made within 120 days immediately preceding the commencement of this
case. (Married debtors filing under chapter 12 or chapter 13 must
include any assignment by either or both spouses whether or not a joint
petition is filed, unless the spouses are separated and a joint
petition is not filed.)
NAME AND ADDRESS DATE OF ASSIGNMENT
OF ASSIGNEE ASSIGNMENT OR SETTLEMENT
b. List all property which has been in the hands of a custodian,
receiver, or court-appointed official within one year immediately
preceding the commencement of this case. (Married debtors filing under
chapter 12 or chapter 13 must include information concerning property
of either or both spouses whether or not a joint petition is filed,
unless the spouses are separated and a joint petition is not filed.)
NAME AND LOCATION DESCRIPTION
NAME AND ADDRESS OF CUSTODIAN DATE OF AND VALUE OF
OF CUSTODIAN CASE TITLE & NUMBER ORDER PROPERTY
Gifts
List all gifts or charitable contributions made within one year
immediately preceding the commencement of this case except ordinary and
usual gifts to family members aggregating less than $200 in value per
individual family member and charitable contributions aggregating less
than $100 per recipient. (Married debtors filing under chapter 12 or
chapter 13 must include gifts or contributions by either or both
spouses whether or not a joint petition is filed, unless the spouses
are separated and a joint petition is not filed.)
NAME AND ADDRESS RELATIONSHIP DESCRIPTION
OF PERSON TO DEBTOR, DATE AND VALUE
OR ORGANIZATION IF ANY OF GIFT OF GIFT
Losses
List all losses from fire, theft, other casualty or gambling within
one year immediately preceding the commencement of this case or since
the commencement of this case. (Married debtors filing under chapter
12 or chapter 13 must include gifts or contributions by either or both
spouses whether or not a joint petition is filed, unless the spouses
are separated and a joint petition is not filed.)
DESCRIPTION DESCRIPTION OF CIRCUMSTANCES AND, IF
AND VALUE OF LOSS WAS COVERED IN WHOLE OR IN PART DATE OF
PROPERTY BY INSURANCE, GIVE PARTICULARS LOSS
Payments related to debt counseling or bankruptcy
List all payments made or property transferred by or on behalf of the
debtor to any persons, including attorneys, for consultation concerning
debt consolidation, relief under the bankruptcy law or preparation of a
petition in bankruptcy within one year immediately preceding the
commencement of this case.
DATE OF PAYMENT, AMOUNT OF MONEY OR
NAME AND ADDRESS NAME OF PAYOR IF DESCRIPTION AND VALUE
OF PAYEE OTHER THAN DEBTOR OF PROPERTY
Other transfers
List all the property, other than property transferred in the
ordinary course of the business or financial affairs of the debtor,
transferred either absolutely or as security within one year
immediately preceding the commencement of this case. (Married debtors
filing under chapter 12 or chapter 13 must include gifts or
contributions by either or both spouses whether or not a joint petition
is filed, unless the spouses are separated and a joint petition is not
filed.)
NAME AND ADDRESS OF TRANSFEREE, TRANSFERRED
RELATIONSHIP TO DEBTOR DATE AND VALUE RECEIVED
Closed financial accounts
List all financial accounts and instruments held in the name of the
debtor or for the benefit of the debtor which were closed, sold, or
otherwise transferred within one year immediately preceding the
commencement of this case. Include checking, savings, or other
financial accounts, certificates of deposit, or other instruments;
shares and share accounts held in banks, credit unions, pension funds,
cooperatives, associations, brokerage houses and other financial
institutions. (Married debtors filing under chapter 12 or chapter 13
must include gifts or contributions by either or both spouses whether
or not a joint petition is filed, unless the spouses are separated and
a joint petition is not filed.)
TYPE AND NUMBER AMOUNT AND
NAME AND ADDRESS OF ACCOUNT AND DATE OF SALE
OF INSTITUTION AMOUNT OF FINAL BALANCE OR CLOSING
Safe deposit boxes
List each safe deposit or other box or depository in which the
debtor has or had securities, cash, or other valuables within one year
immediately preceding the commencement of this case. (Married debtors
filing under chapter 12 or chapter 13 must include gifts or
contributions by either or both spouses whether or not a joint petition
is filed, unless the spouses are separated and a joint petition is not
filed.)
NAME AND ADDRESS NAMES AND ADDRESSES DESCRIPTION DATE OF TRANSFER
OF BANK OR OF THOSE WITH ACCESS OF OR SURRENDER,
OTHER DEPOSITORY TO BOX OR DEPOSITORY CONTENTS IF ANY
Setoffs
List all setoffs made by any creditor, including a bank, against a
debt or deposit of the debtor within 90 days preceding the commencement
of this case. (Married debtors filing under chapter 12 or chapter 13
must include gifts or contributions by either or both spouses whether
or not a joint petition is filed, unless the spouses are separated and
a joint petition is not filed.)
DATE OF AMOUNT OF
NAME AND ADDRESS OF CREDITOR SETOFF SETOFF
Property held for another person
List all property owned by another person that the debtor holds or controls.
NAME AND ADDRESS DESCRIPTION AND VALUE
OF OWNER OF PROPERTY LOCATION OF PROPERTY
Prior address of debtor
If the debtor has moved within the two years immediately preceding
the commencement of this case, list all premises which the debtor
occupied during that period that period and vacated prior to the
commencement of this case. If a joint petition is filed, report also
any separate address of either spouse.
ADDRESS NAME USED DATES OF OCCUPANCY
The following questions are to be completed by every debtor that is a
corporation or partnership and by any individual debtor who is or has
been, within the two years immediately preceeding the commencement of
this case, any of the following: an officer, director, managing
executive, or owner of more than 5% of the voting securities of a
corporation: a partner, other than a limited partner, of a partnership;
a sole proprietor or otherwise self-employed.
(An individual or joint debtor should complete this portion of
the statement only if the debtor is or has been in business, as
defined above, within the two years immediately preceeding the
commencement of this case.)
Nature, location and name of business
a. If the debtor is an individual, list the names and addresses of
all businesses in which the debtor was an officer, director, partner,
or managing executive of a corporation, partnership, sole
proprietorship, or was a self-employed professional within the two
years immediately preceeding the commencement of this case, or in which
the debtor owned 5 percent or more of the voting or equity securities
within the two years immediately preceeding the commencement fo this
case.
NAME ADDRESS NATURES OF BEGINNING
BUSINESS AND ENDING
DATES OF
OPERATION
Books, records and financial statements.
a. List al bookkeepers and accountants who within the six years immediately
preceeding the filing of this bankruptcy case kept or supervised the keeping of books of account and
records of the debtor.
NAME AND ADDRESS DATES SERVICES RENDERED
b. List all firms or individuals who within the two years immediately preceeding the
filing of this bankruptcy case have audited the books of account and records, or prepared a financial
statement of the debtor.
NAME AND ADDRESS DATES SERVICES RENDERED
c. List all firms or individuals who at the time of the commencement of this case
were in possession of the books of account and records of the debtor. If any of the books of account and
records are not available, explain.
NAME AND ADDRESS ADDRESS
d. List all financial institutions, creditors and other parties, including mercantile and
trade agencies, to whom a financial statement was issued within the two years immediately preceeding the
commencement of this case by the debtor.
NAME AND ADDRESS DATE ISSUED
Inventories
a. List the dates of the last two inventories taken of your property, the name of the
person who supervised the taking of each inventory, and the dollar amount and basis of each inventory.
DATE OF INVENTORY INVENTORY SUPERVISOR DOLLAR AMOUNT
b. List the name and address of the person having possession of the records of each
of the two inventories reported in a., above.
DATE OF INVENTORY NAME AND ADDRESS OF CUSTODIAN OF RECORDS
Current Partners, Officers, Directors and Shareholders
a. If the debtor is a partnership, list the nature and percentage of partnership
interest of each member of the partnership.
NAME AND ADDRESS NATURE OF INTEREST PERCENTAGE OF INTEREST
b. If the debtor is a corporation, list all officers and directors of the corporation, and
each stockholder who directly or indirectly owns, controls, or holds 5 percent or more of the voting securities of
the corporation.
NAME AND ADDRESS TITLE NATURE AND PERCENTAGE OF
STOCK OWNERSHIP
Former partners, officers, directors and shareholders
a. If the debtor is a partnership, list each member who withdrew from the
partnership within one year immediately preceeding the commencement of this case.
NAME AND ADDRESS DATE OF WITHDRAWAL
b. If the debtor is a corporation, list all officers, or directors whose relationship with
the corporation terminated within one year immediately preceeding the commencement of this case.
NAME AND ADDRESS TITLE DATE OF TERMINATION
Withdrawal from a partnership or distribution by a corporation.
a. If the debtor is a partnership or corporation, list all withdrawals or distributions
credited or given to an insider, including compensation in any form, bonuses, loans, stock redemptions, options
exercised and any other perquisite during one year immediately preceeding the commencement
of this case.
NAME AND ADDRES OF RECIPIENT DATE AND AMOUNT OF
AND RELATIONSHIP TO DEBTOR PURPOSE OF MONEY OR DESCRIPTION
WITHDRAWAL AND VALUE OF
PROPERTY