Petition Information

What is your full name?

What is your spouse's full name?

Your Social Security Number      Spouse's Social Security Number

What is your address?    City    Zip

Mailing address if different than above?    City    Zip

Home Telephone Number      Your Cell Phone     Your Work Phone

Are your spouse's addresses the same?    Yes     No

Have you resided there for the last 6 months?    Yes     No

Are you engaged in a business other than as an employee?    Yes     No

Has a bankruptcy case been filed by or against you or your spouse within the past 8 years?    Yes    No

Is there a bankruptcy case now pending against you or your spouse or against a business partner or associate of yours?    Yes    No

Schedule A Information - Your Real Estate

Do you or your spouse own or are your buying a house, piece of land or other real estate?
   Yes    No

Please list the following for each piece of real estate:

• Address
• Nature of you and your spouse's interest in the property
• Date property was acquired
• Estimated market value
• Amount of each mortgage or lein

Schedule B Information - Your Personal Property

How much cash do you and your spouse have? (Do not include cash held in a bank)  $

Do you or your spouse have any checking or savings accounts, deposits, or shares in any bank or financial institution?    Yes    No

If so, please list the following for each account, deposit or share:

• Name and address of financial institution
• Name under which it is registered
• Amount

Do you or your spouse have any deposits with a landlord, telephone company, utility company, or anyone else?    Yes    No

If so, please state:

• Who made each deposit
• The amount of each deposit
• The name and address of the holder of each deposit

Do you or your spouse own any household goods or furnishings, including audio, video, or computer equipment?  Yes    No

If so, what is the approximate value of all household goods combined? (Please estimate) $

Do you or your spouse own any books, pictures, art objects, antiques, stamp, coin, record, tape, compact disc, or other collections or collectibles?  Yes    No

If so, describe each item and state the following for each item:

• Estimated market value
• Its owner

What is the total market value (rummage sale value) of all of your and your spouses wearing apparel?    $

Do you or your spouse own any furs or jewelry?  Yes    No

If so, identify each item and state the following for each item:

• Estimated market value
• Its owner

Do you or your spouse own any firearms, sports equipment, photographic equipment, or other hobby equipment?  Yes    No

If so, identify each item and state the following for each item:

• Estimated market value
• Its owner

Do you or your spouse own an interest in a life insurance policy?  Yes    No

If so, identify each policy by:

• Policy number
• Owner
• Name of insurance company
• List of the cash surrender or refund value of each policy

Do you or your spouse own or have an interest in an annuity?  Yes    No

Do you or your spouse own an interest in an interest in an IRA, ERISA, Keough, or other retirement, pension, or profit sharing plan?  Yes    No

If so, identify each plan and list the present value of the interest of you or your spouse in each plan:

Do you or your spouse own any stock in a corporation or an interest in any partnership, joint venture, or other business?  Yes    No

Do you or your spouse own any government or corporate bonds?  Yes    No

Do you or your spouse own any accounts receivables?  Yes    No

Are you or your spouse owed any accrued and unpaid alimony, maintenance, support, or property settlement payments?  Yes    No

Are you or your spouse entitled to any tax refunds or other money, then amount of which has been determined?  Yes    No

Do you or your spouse own or have an equitable or future interest in any property?  Yes    No

Do you or your spouse own or have an interest of any kind in the estate of a deceased person, in a death benefit plan, in the the death benefits in a life insurance policy, or in a trust?  Yes    No

Do you or your spouse own have any counterclaims or rights or setoff against other persons, the amount of which is presently unclear or undetermined?  Yes    No

Do you or your spouse own or have an ownership interest in any patents, copyrights, or other intellectual property?  Yes    No

Do you or your spouse own or have an ownership interest in any license, franchise, or similiar property?  Yes    No

Do you or your spouse own or are you buying any cars, trucks, trailers, or other vehicles or accessories?  Yes    No

If so, for each vehicle, describe the following:

• Make and model
• Its owners
• Its estimated value

Do you or your spouse own or have an ownership interest in any boats, motors, or accessories?
 Yes    No

If so, for each vehicle, describe the following:

• Item
• Its location
• Market value
• Its owner

Do you or your spouse own or have an ownership interest in any aircraft or accessories?
 Yes    No

Do you or your spouse own any office equipment, office furnishings, or office supplies?
 Yes    No

If so, for each list each item and state:

• Estimated market value
• Its owner

Do you or your spouse have any interest in any machinery, fixtures, equipment, or supplies used in business?
 Yes    No

Do you or your spouse have any interest in any commerical inventory?
 Yes    No

Do you or your spouse have any ownership interest in any animals?
 Yes    No

If so, describe each animal, and state the following:

• Its location
• Estimated market value
• Its owner

Do you or your spouse have any ownership interest in any growing crops or crops?
 Yes    No

Do you or your spouse have any ownership interest in any farm equipment or implements?
 Yes    No

Do you or your spouse own any farm supplies, chemicals, or feed?
 Yes    No

Do you or your spouse own or have an ownership in any personal property of any kind that has not been listed above?
 Yes    No

If so, describe the property and state:

• Its location
• Estimated market value
• Its owner

Schedule E Information - Your Priority Unsecured Debts

Do you or your spouse owe any debts for wages, salaries, or commissions, including vacation, severence, or sick leave pay?
 Yes    No

Do you or your spouse owe any debts for unpaid employer's contributions to employee benefit plans? (Including 401(K) and life insurance loans through employer).
 Yes    No

Do you or your spouse operate a grain storage facility or a fish produce storage or processing facility?
 Yes    No

Do you or your spouse owe any debts for the return of deposits made for the purchase, lease, or rental of property or services that were not provided?
 Yes    No

Do you or your spouse owe any debts to a spouse, former spouse, or child for alimony, maintenance, or support (Only answer yes if you are in arrearages)?
 Yes    No

If so, provide a copy of the separation agreement, court order, or decree that created the debt, and please list below:

• The amount owed
• The name and address of the person that is owed the debt

Do you or your spouse owe any debts any local, state, or federal government for taxes, customs, duties, or penalties?
 Yes    No

If so, for each debt, list below:

• The name and address of the governmental entity to who it's owed
• The amount owed
• The date it first became due
• The persons liable for the debt

Schedule G Information - Your Existing Contracts and Leases

Are you and your spouse a party to any current contracts or leases (including apartment and car leases)?
 Yes    No

If so:

• Describe each contract or lease
• List the name and address of all parties to the contract or lease

Schedule H Information - Codebtors

Is anybody beside yourself liable for any of your or your spouse's debts?
 Yes    No

If so, the name and address of each person that is liable with you for a particular debt should appear in line 5 of the DEBT FORM filled out for that debt.

Schedule I Information - Your Current Income

List the name, age, and relationship of each of your dependents

List the name and address of your employer, your occupation, and length of employment.

List the name and address of your spouse's employer, their occupation, and length of employment.

	YOUR INCOME	YOUR SPOUSE'S
1. Current monthly gross wages, salary and commissions
2. Estimated monthly overtime
3. Subtotal (add lines 1 & 2)
LESS PAYROLL DEDUCTIONS
4.    a. Payroll taxes and social security
5.    b. Insurance
6.    c. Union Dues
7.    d. Other (Specify)
8. SUBTOTAL OF PAYROLL DEDUCTIONS     (add lines 4,5,6,&7)
9. TOTAL NET MONTHLY TAKE HOME PAY     (subtract line 8 from line 3)
10. Regular income from operation of business       or profession or farm       Describe:
11. Income from real property
12. Interest and dividends
13. Alimony, maintenance or support payments payable to the debtor for the debtor's use or that of dependents listed above.
14. Social security or other government assistance       Specify:
15. Pension or Retirement Income
16. Other monthly income       Specify:
17. TOTAL MONTHLY INCOME       (add lines 9,10,11,12,13,14,15 & 16)
TOTAL COMBINED MONTHLY INCOME       (you and your spouse combined)

Schedule J Information - Your Current Expenditures

Complete the following by estimating the average monthly expenses of yourself and your family. Payments that are made other than monthly should be pro-rated to a monthly amount if possible. Otherwise, make an appropriate notation.

If a joint petition is being filed and if your spouse maintains a separate husehold, make a separate list of expenditures for your spouse to the right of your list.

	YOUR EXPENDITURES	YOUR SPOUSE'S (if separate household)
Rent or home mortgage payment (include lot rented for mobile home) Are real estate taxes included?  Yes    No
UTILITIES
Electricity and heating fuel
Water and sewer
Telephone
Other (cell phone, cable TV, internet, etc.)       Specify:
Home maintenance (repairs and upkeep)
Food
Clothing
Laundry and dry cleaning
Medical and dental expenses
Transportation and gasoline (not including car payments)
Recreation, entertainment, subscriptions
Charitable contributions
INSURANCE (not deducted from wages or included                    in home mortgage payments)
Homeowner's or renters
Life
Health
Auto
Other
TAXES (not deducted from wages or included in home mortgage            payments)        Specify:
INSTALLMENT PAYMENTS (In Chapter 12 & 13 cases, do not list payments to be included in the plan)
Auto
Other
Other
Other
Alimony, maintenance and support paid to others
Payment for support of additional dependants not living at your home
Regular expenses from operation of business, profession or farm        Specify:
Other Payments
Other Payments
TOTAL COMBINED MONTHLY EXPENSES       (you and your spouse combined)

Statement of Financial Affairs Information

How much gross income have you and your spouse received from your employment or business in this calendar year?

If you operate your business on a fiscal year other than calendar year, substitute fiscal year for calendar year in this and the following 3 questions.

            You $

Your Spouse $

How much gross income have you and your spouse received from your employement or business during each of the last calendar years?

          Last year: You $     Your Spouse $

  Year before last: You $     Your Spouse $

How much income have you and your spouse received other than from your employement or business during the last two calendar years?

          Last year: You $     Your Spouse $

  Year before last: You $     Your Spouse $

What was the source of this income?

Have you or your spouse paid more than $600 total to any creditor in the last 90 days?
 Yes    No

If so, for each creditor, list the following:

• Name and address
• Date of payment
• Who made the payment
• Amount paid
• Amount still owed

Have you or your spouse made any payments to (or for the benefit of) a relative or business associate of any kind within the past 2 years?
 Yes    No

If so, for each payment state:

• Name and address
• Relationship of creditor to you
• Date of payment
• Who made the payment
• Amount paid
• Amount still owed

Have you or your spouse been involved in any lawsuits as a party during the last 365 days?
 Yes    No

If so, for each lawsuit state:

• Name of case and case number
• Nature of the case
• The court
• Status or disposition of the case

Have you or your spouse had any money or property attached, garnished or seized in a court proceeding within the last 365 days?
 Yes    No

If so, describe the property seized and state:

• Name and address of creditor
• Date of seizure
• Owner of property seized

Has any property owned by yourself or your spouse been repossessed by a creditor, foreclosed upon, or otherwise returned to the seller within the last 365 days?
 Yes    No

If so, describe the property seized and state:

• Name and address of creditor or seller
• Date of repossession, foreclosure or return
• Value of property
• Owner of property

Have you or your spouse made an assignment for the benefit of creditors within the last 120 days?
 Yes    No

If so, please provide us with copies of all papers relating to the assignment.

Has any of your property or your spouse's property been held by a custodian, receiver, or other court-appointed official during the last 365 days?
 Yes    No

If so, please provide us with copies of all papers relating to the proceeding.

Have you or your spouse made any charitable contributions within the last 365 days, except ordinary gifts to family members totaling less than $200 per recipient, and charitable contributions of less than $100 per recipient.
 Yes    No

If so, describe the gift and state:

• Name and address of recipient
• Relationship of recipient to you
• Date of gift
• Value of gift
• Person who made the gift

Have you or your spouse had any losses from fire, theft, or other casualty, or from gambling during the last 365 days?
 Yes    No

If so, state:

• Type of loss
• Property lost
• Date of loss
• Amount of loss
• Whether covered by insurance
• Person who incurred the loss

Has any money been transferred by or behalf of you or your spouse to attorneys or other persons for debt consolidation or the filing of a bankruptcy case within the last 365 days?
 Yes    No

If so, state:

• Name and address of person paid
• Date of payment
• Name of person who made transfer
• Amount paid or value and description of property transferred

Have you or your spouse transferred any money or property within the last 365 days other than property or money transferred in the ordinary course of your business or financial affairs?
 Yes    No

If so, describe the property transferred an state:

• Name and address of traansferee
• Relationship of transferee to you
• Date of transfer
• Value of property transferred
• Owner of property transferred

Have you or your spouse closed, transferred or sold any checking, savings, or other financial accounts, certificates of deposit, and shares in banks, credit unions or other financial institutions within the last 365 days?
 Yes    No

If so, state:

• Name and address of financial institution
• Name of account, account number and type of account
• Amount of final balance in account
• Date of any sale and amount received

Have you or your spouse kept cash, securities, or other valuables in a safety deposit box or other boxes or depository within the last 365 days?
 Yes    No

If so, describe the contents and state:

• Name and address of bank or depository
• Date of transfer or surrender, if any

Has any creditor, including a bank, made a setoff against you or your spouse within the last 90 days?
 Yes    No

If so, list the name and address of the creditor and the date and amount of the setoff:

Do you or your spouse hold or control any property owned by another person?
 Yes    No

If so, list the name and address of the owner, describe the property, and list its value and location:

Have you or your spouse moved during the last 24 months?
 Yes    No

If so, state:

• Address of each place where either of you have lived during that period
• Name or names used at that address
• Dates of occupancy

Have you or your spouse within the last two years, been any of the following:

• an officer, director, managing executive, or the owner of more than 5% of the voting stock of a corporation
• a general partner of a partnership
• a sole proprietor or self-employed person?

    Yourself: Yes    No           Your Spouse:  Yes    No