PERSONAL FINANCIAL INFORMATION

1)	Name:	     	Date	     	
		First	Middle	Last 		
		
	Other names used:	     		
		First 	Middle 	Last 		
		
	Citizenship status:	     	
		
	Address:	     	
		
	Social Security Number:	     		
	
2)	How long have you lived at your current address?	     		
		
	List any other addresses for the past 5 years:	
		
	Address:	     	
		
	Address:	     	
	
3)	Marital Status:	 Married   Divorced   Separated   Single   Widowed/Widower	
		
	If married, please list the name of your spouse:	     	
		
	Is your spouse filing bankruptcy?	 Yes   No	
		
	If yes, please list your spouse’s address and Social Security Number 	
		
	Address:	     	
		
	Social Security Number:	     		
	
4)	List the names and ages of your dependants, if any:	
		
	Name:	     		
		
	Age:	     		
		
	Relationship:	     		
		
	Name:	     		
		
	Age:	     		
		
	Relationship:	     				
		
	Name:	     		
		
	Age:	     		
		
	Relationship:	     		
	
5)	List your monthly income.  Identify the source (employment, spousal support, SSA, etc.), the gross monthly amount, and the net (take-home) amount.	

	Name of Employer/Your Monthly Income	Gross	Net	
	     	$     	$     	
	     	$     	$     	
	     	$     	$     	
	Totals 	$     	$     	
		
	NOTE:  Monthly income is not limited to income from employment, but includes social security and supplemental security income, Temporary Assistance for Needy Families (TANF), disability, child support, annuities, food stamps, retirement benefits, etc.	
	
6)	Do you have health insurance for:	
		
	Yourself:	 Yes   No	
		
	If yes, who is the provider?	     	
		
	Spouse:	 Yes   No	
		
	If yes, who is the provider?	     	
		
	Children/Dependants:	 Yes   No	
		
	If yes, who is the provider?	     	
	
7)	Have you ever filed bankruptcy before?	 Yes   No	
		
	If yes, please list the following:	
		
	Location where filed:	     	
		
	Case number:	     		
		
	Date filed:	     		
		
	Discharge date:	     		
	
8)	Is your spouse in bankruptcy?	 Yes   No	
	
9)	Please list all real estate (for example your home) in which you have an interest:	
		
	Type of property:	     	
		
	Address:	     	
		
	Market value:	     		
		
	Type of property:	     	
		
	Address:	     	
		
	Market value:	     		
		
	Type of property:	     	
		
	Address:	     	
		
	Market value:	     		
		
	Type of property:	     	
		
	Address:	     	
		
	Market value:	     		
	
10)	How much cash do you normally have on hand?	     		
	
11)	Do you have a bank account?	 Yes   No	
		
	Account number:	     		
		
	Name of bank:	     		
		
	Address:	     	
		
	Account number:	     		
		
	Name of bank:	     		
		
	Address:	     	
	
12)	Security Deposits	
		
	Landlord:	     	
		
	Public Utilities:	     	
		
	Telephone:	     	
		
	Others: 	     	
	
13)	Estimate value, and where appropriate, give the quantity of any of the following property that you own:	

		Color TV	$     		Home computer	$     	
		B & W TV	$     		Sofa 	$     	
		VCR	$     		Tables	$     	
		Microwave	$     		Stereo	$     	
		Chairs	$     		Bookcases	$     	
		Lamps	$     		Beds, bedding	$     	
		Dressers 	$     		Dishes	$     	
		Silverware 	$     		Appliances	$     	
		Tools 	$     		Carpets	$     	
		Books 	$     		Pictures	$     	
		Antiques 	$     		Refrigerator	$     	
		Clothes 	$     		Wedding/engagement rings	$     	
		     	$     		     	$     	
	
14)	All jewelry:  watches, chains, rings, other	     		
	
15)	List any IRA, KEOGH, or other pension or profit-sharing plans in which you have an interest:	

	Type of plan: 	     	
		
	Institution name:	     	
		
	Address:	     	
		
	Account number:	     		
		
	Amount in account:	     		
		
	Type of plan: 	     	
		
	Institution name:	     	
		
	Address:	     	
		
	Account number:	     		
		
	Amount in account:	     		
		
	Type of plan: 	     	
		
	Institution name:	     	
		
	Address:	     	
		
	Account number:	     		
		
	Amount in account:	     		
	
16)	Do you own any stocks, bonds, annuities, etc.?	 Yes   No	
		
	Please list with whom, and how much:	
		
	Institution name:	     	
		
	Address:	     	
		
	Account number:	     		
		
	Amount in account:	     		
		
	Institution name:	     	
		
	Address:	     	
		
	Account number:	     		
		
	Amount in account:	     		
	
17)	Are you, or do you anticipate receiving any tax refunds in the next 180 days? 
 Yes   No	

	If so, please estimate how much:	     		
	
18)	Do you have any life insurance policies with a cash value?	 Yes   No	
		
	List the agency and the amount:	
		
	Insurance agency:	     	
		
	Address:	     	
		
	Account number:	     		
		
	Amount in account:	     		
		
	Insurance agency:	     	
		
	Address:	     	
		
	Account number:	     		
		
	Amount in account:	     		
	
19)	List all motor vehicles that you own	
		
	Make and model:	     	
		
	Year:	     		
		
	Value:	     		
		
	How much owed:	     		
		
	Co-owner(s):	     	
		
	Make and model:	     	
		
	Year:	     		
		
	Value:	     		
		
	How much owed:	     		
		
	Co-owner(s):	     	
	
20)	Does anyone owe you any money?     Yes   No 
(Include support payments) If so, who, and how much:	

	Name:	     	
		
	Address:	     	
		
	Amount:	     		
		
	Type of debt:	
	     
     
     
     
     
     	

		

	
21)	Please provide an itemized list of your monthly expenses:	
		
1.	HOUSING		8.	PERSONAL		
	Rent/Mortgage	$     		Beauty/Barber	$     	
	2nd Mortgage/Home equity	$     		Other	$     	
	Condo/HOA dues	$     	9.	ENTERTAINMENT		
	Property Taxes	$     		Cable	$     	
	Renter’s/Homeowner’s Ins.	$     		Movie/Video	$     	
	Gas/Electric	$     		Dining Out	$     	
	Water/Sewer	$     		Sports/Hobbies/Clubs/Gym	$     	
	Garbage 	$     		Vacations/Travel	$     	
	Telephone	$     		Reading Material/Music	$     	
2.	FOOD		10.	CLOTHING		
	Groceries	$     		Purchases	$     	
	Household Items	$     		Laundry/Dry Cleaning	$     	
	Lunches (Work/School)	$     	11.	HOME CARE		
3.	MEDICAL			Maintenance/Repairs	$     	
	Health Ins.	$     		Cleaning 	$     	
	Prescriptions 	$     		Pool Service/Lawn Service	$     	
4.	TRANSPORTATION			Security System	$     	
	Car Payment #1	$     	12.	MISCELLANEOUS		
	Car Payment #2	$     		Pet Care	$     	
	Gasoline/Fuel	$     		Pager/Cell Phone	$     	
	Repairs/Maintenance	$     		Banking Fees	$     	
	Insurance	$     		Postage	$     	
	DMV Registration	$     		Cigarettes	$     	
	Tolls/Parking	$     		Alcohol 	$     	
	Bus/Subway	$     		Gifts	$     	
	Property Taxes	$     		Internet/Computer Fees	$     	
5.	CHILD CARE			Charity Donations	$     	
	Daycare/Sitting	$     		Other		
	Alimony/Child Support	$     				
6.	EDUCATION					
	Tuition	$     				
	Student Loans	$     				
7.	MISCELLANEOUS					
	Taxes	$     				
	Life Insurance	$     				
	Union Dues	$     				
	Savings	$     				
	Retirement	$     				
	Other 	$     				
Total Essential	$     		Total Non-Essential	$     	
	
22)	Please provide a listing of your creditors (Use your Credit Report):	
	
CREDITOR	ADDRESS	ACCOUNT NO.	BALANCE DUE	WHETHER DELINQUENT	
     	     	     	$     	     	
     	     	     	$     	     	
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     	     	     	$     	     	
     	     	     	$     	     	
TOTAL BALANCE DUE	$     		
	
23)	Please provide a listing of any judgments obtained against you:	
	
Court	Case No.	Date of Judgment	Amount	
     	     	     	$     	
     	     	     	$     	
     	     	     	$     	
     	     	     	$     	
     	     	     	$     	
     	     	     	$     	
     	     	     	$     	
	
24)	Additional Information: