GENERAL INFORMATION |
Please fill out ALL the information requested in this form. If a question or section does NOT apply to you type "N/A" in
the space. (N/A means "not applicable") The more information you provide in this form, the faster your bankruptcy petition can be prepared. There will be a delay if we need
to verify or obtain more information concerning a specific asset, debt or creditor; so please provide as much detail as you can and fill in ALL the information requested. Thank you for taking the
time to be thorough and complete, resulting in faster turnaround. |
| How were you referred to The Galler Law Firm? |
| First Name:
|
Middle (Spell Out): |
Last Name:
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| Social Security Number:
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Date of Birth:
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| Address:
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City:
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State:
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Zip Code:
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| County of Residence: |
Length of time at this address: |
| Home Phone: |
Other Phone: |
Cell Phone: |
| Email Address: |
| Mailing Address - If you would like any correspondence by the bankruptcy court to be sent to a different address than the physical address you
provided above (i.e, PO Box, etc.), please provide that address below: |
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INFORMATION ABOUT YOUR SPOUSE |
| Spouse First Name: |
Middle (Spell Out): |
Last Name: |
| Social Security Number: |
Date of Birth: |
| Address (if living separately): |
City:
|
State
:
|
Zip Code: |
| Emergency Contact: |
Phone Number: |
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| Have you resided in the same county for at least 180 days? (6 months)
Yes
No |
| If not, where have you resided? |
| Are you filing this bankruptcy petition with your spouse?
Yes
No |
| If no, please check one:
Unmarried
Spouse Filing Separately
Other Reason |
| Have you filed bankruptcy within the last eight (8) years?
Yes
No |
| If yes, please provide date(s): |
| Have you met the Debt Counseling requirement for your state? Please check one of the choices below: |
|
Counseling not completed
Received counseling within the past 180 days (please bring copy to consultation) |
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INFORMATION FOR MEANS TEST |
|
Means Test does NOT apply. Debtor(s) is a disabled veteran with debts incurred primarily during active duty or homeland defense. |
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DEPENDENTS |
Name:
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Age
:
|
| Relationship to You: |
Is this person/child living with you?
Yes
No |
Name:
|
Age
:
|
| Relationship to You:
|
Is this person/child living with you?
Yes
No |
Name:
|
Age
:
|
| Relationship to You:
|
Is this person/child living with you?
Yes
No |
Name:
|
Age
:
|
| Relationship to You:
|
Is this person/child living with you?
Yes
No |
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INCOME FOR SIX (6) MONTHS |
Provide the total amount of earned income (from all sources) that you received for the last six complete (6) months of income. DO NOT
DEDUCT TAXES. The income you report below is NOT TAKE-HOME PAY but the TOTAL INCOME YOU ACTUALLY EARNED BEFORE TAXES WERE DEDUCTED. |
| Husband: Wages, salaries, tips, bonuses, overtime, and commissions: |
| Last Month: |
2 Months Ago: |
3 Months Ago: |
| 4 Months Ago: |
5 Months Ago: |
6 Months Ago: |
| Wife: Wages, salaries, tips, bonuses, overtime, and commissions: |
| Last Month:
|
2 Months Ago:
|
3 Months Ago:
|
| 4 Months Ago: |
5 Months Ago: |
6 Months Ago: |
| Husband: Income from operation of business, profession or farm: |
| Last Month: |
2 Months Ago: |
3 Months Ago: |
| 4 Months Ago: |
5 Months Ago: |
6 Months Ago: |
| Wife: Income from operation of business, profession, or farm: |
| Last Month: |
2 Months Ago: |
3 Months Ago: |
| 4 Months Ago: |
5 Months Ago: |
6 Months Ago: |
| Husband: Rents and other property income (not rent you paid, but rents paid to you): |
| Last Month: |
2 Months Ago: |
3 Months Ago: |
| 4 Months Ago: |
5 Months Ago: |
6 Months Ago: |
| Wife: Rents and other property income (not rent you paid, but rents paid to you): |
| Last Month: |
2 Months Ago: |
3 Months Ago: |
| 4 Months Ago: |
5 Months Ago: |
6 Months Ago: |
| Husband: Interest income, dividends, and royalties: |
| Last Month: |
2 Months Ago: |
3 Months Ago: |
| 4 Months Ago: |
5 Months Ago: |
6 Months Ago: |
| Wife: Interest income, dividends, and royalties: |
| Last Month: |
2 Months Ago: |
3 Months Ago: |
| 4 Months Ago: |
5 Months Ago: |
6 Months Ago: |
| Husband: Pension and retirement income: |
| Last Month: |
2 Months Ago: |
3 Months Ago: |
| 4 Months Ago: |
5 Months Ago: |
6 Months Ago: |
| Wife: Pension and retirement income: |
| Last Month: |
2 Months Ago: |
3 Months Ago: |
| 4 Months Ago: |
5 Months Ago: |
6 Months Ago: |
| Husband: Income received from others who are not filing bankruptcy with you who contribute money to the household expenses: |
| Last Month: |
2 Months Ago: |
3 Months Ago: |
| 4 Months Ago: |
5 Months Ago: |
6 Months Ago: |
| Wife: Income received from others who are not filing bankruptcy with you who contribute money to the household expenses: |
| Last Month: |
2 Months Ago: |
3 Months Ago: |
| 4 Months Ago: |
5 Months Ago: |
6 Months Ago: |
| Husband: Unemployment compensation: |
| Last Month: |
2 Months Ago: |
3 Months Ago: |
| 4 Months Ago: |
5 Months Ago: |
6 Months Ago: |
| Wife: Unemployment compensation: |
| Last Month: |
2 Months Ago: |
3 Months Ago: |
| 4 Months Ago: |
5 Months Ago: |
6 Months Ago: |
| Husband: Income from other sources not provided for above: |
| Last Month: |
2 Months Ago: |
3 Months Ago: |
| 4 Months Ago: |
5 Months Ago: |
6 Months Ago: |
| Wife: Income from other sources not provided for above: |
| Last Month: |
2 Months Ago: |
3 Months Ago: |
| 4 Months Ago: |
5 Months Ago: |
6 Months Ago: |
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OTHER INFORMATION |
| Has either you or your spouse been known by any other name during the past 8 years?
Yes
No |
| (Example: maiden name, last name from previous marriage, legal name change, etc.) |
| If yes, write the NAME KNOWN AS and DATE(s) THIS NAME USED below: |
| Name Used: |
Dates Used: |
Thru:
|
| Name Used: |
Dates Used: |
Thru:
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FEDERAL INCOME TAX RETURNS |
| Have you filed a Federal income tax return for every tax year a return has been due?
Yes
No |
| If no, what years have you not filed: |
| If yes, have you provided us with your most recent return?
Yes
No |
| Has your income significantly increased or decreased during the past six (6) months? If so, please provide details below:
|
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INCOME HISTORY FOR YOU |
| Your name as listed on your current paycheck stub: |
| Year-to-Date Total for this current year: |
VERY IMPORTANT: |
Gross Income last year: |
Gross Income 2 Years Ago: |
| Employer's Name: |
Phone Number: |
| Address: |
City:
|
State:
|
Zip Code: |
| length of Time at Job: |
Years:
|
Months: |
| Job Title (do not abbreviate): |
How often do you get paid? (check one)
Every Week
Once a Month
Bi-Weekly (sometimes 3 times/month)
Semi-Monthly (same 2 days each month) |
| What is your "average" gross wages before deductions?
|
| "Average" extra money you receive in overtime and commissions per pay period:
|
| Total amount of taxes deducted (FICA, Federal, State, Local) from your paycheck:
|
| How much do you pay in Alimony or Child Support if any?
|
| Are you court ordered to pay this?
Yes
No |
| Are there any other deductions from your paycheck?
Yes
No If yes, how much?
|
| What is this "other" deduction for?
|
| If 401K Plan, how long have you participated?
|
| How much additional income do you make monthly from a business, flea market, etc?
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| Monthly Income from real property (rentals):
|
| Monthly Alimony or Child Support received:
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| Monthly Government Assistance:
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| Monthly Public Assistance:
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| Monthly Interests and Dividends:
|
| Monthly Social Security:
|
| Monthly Food Stamps:
|
| Monthly Pension or Retirement:
|
| Other Income (reason and amount received monthly):
|
| Do you have a second job?
Yes
No If yes, name of employer:
|
| Address: |
City:
|
State:
|
Zip Code:
|
| Phone Number:
|
|
|
| length of Time at Job:
|
Years:
|
Months:
|
How often do you get paid? (check one)
Every Week
Once a Month
Bi-Weekly (sometimes 3 times/month)
Semi-Monthly (same 2 days each month) |
| What is your "average" gross wages before deductions?
|
| Do you receive any income from a home-based business?
Yes
No |
| If yes, how much per month?
|
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INCOME HISTORY FOR YOUR SPOUSE |
| Your name as listed on your current paycheck stub:
|
| Year-to-Date Total for this current year:
|
VERY IMPORTANT: |
Gross Income last year:
|
Gross Income 2 Years Ago:
|
| Employer's Name:
|
Phone Number:
|
| Address:
|
City:
|
State:
|
Zip Code:
|
| length of Time at Job:
|
Years:
|
Months:
|
| Job Title (do not abbreviate):
|
How often do you get paid? (check one)
Every Week
Once a Month
Bi-Weekly (sometimes 3 times/month)
Semi-Monthly (same 2 days each month) |
| What is your "average" gross wages before deductions?
|
| "Average" extra money you receive in overtime and commissions per pay period:
|
| Total amount of taxes deducted (FICA, Federal, State, Local) from your paycheck:
|
| How much do you pay in Alimony or Child Support if any?
|
| Are you court ordered to pay this?
Yes
No |
| Are there any other deductions from your paycheck?
Yes
No If yes, how much?
|
| What is this "other" deduction for?
|
| If 401K Plan, how long have you participated?
|
| How much additional income do you make monthly from a business, flea market, etc?
|
| Monthly Income from real property (rentals):
|
| Monthly Alimony or Child Support received:
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| Monthly Government Assistance:
|
| Monthly Public Assistance:
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| Monthly Interests and Dividends:
|
| Monthly Social Security:
|
| Monthly Food Stamps:
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| Monthly Pension or Retirement:
|
| Other Income (reason and amount received monthly):
|
| Do you have a second job?
Yes
No If yes, name of employer:
|
| Address:
|
City:
|
State:
|
Zip Code:
|
| Phone Number:
|
|
|
| length of Time at Job:
|
Years:
|
Months:
|
How often do you get paid? (check one)
Every Week
Once a Month
Bi-Weekly (sometimes 3 times/month)
Semi-Monthly (same 2 days each month) |
| What is your "average" gross wages before deductions?
|
| Do you receive any income from a home-based business?
Yes
No |
| If yes, how much per month?
|
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|
HOME BASED BUSINESS OWNERS |
If you have operated a business inside or outside of your home during the past 12 months, please pist below the normal
income and expense your business generated for an average month. If you did not have an average monthly income due to extreme highs and lows in your business, estimate
your total yearly income and divide by 12 to get the average monthly income. Use the same method of determining your average monthly expenses and enter those figures into the spaces
below: |
| Average monthly business income:
|
| Did you withhold any earnings for tax purpose?
Yes
No |
| If yes, how much did you withhold monthly?
|
| Average monthly business expense (if applicable): |
|
| Rent and Utilities:
|
Office Supplies:
|
Product Supplies:
|
| Wages:
|
Equipment Leases:
|
Other Business Leases:
|
Other:
|
$
|
Other:
|
$
|
Other:
|
$
|
Other:
|
$
|
Other:
|
$
|
Other:
|
$
|
| Total Average Monthly Income: |
| Total Average Monthly Expenses: |
| Average Monthly Business Profit: |
| Did you file income taxes for the years you operated your business?
Yes
No |
| If not, what years did you not file? |
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MONTHLY BUDGET |
This form is necessary to determine how much you spend each month on living expense. Be sure to write in the MONTHLY (not yearly)
amounts in the spaces below expenditure. For utilities your bill may be higher in the winter than in the summer, so write an amount that is "average" covering the whole 12 months
period. |
| Housing Expenses: |
|
|
| Rent (if you do not own home):
|
Home Monthly Payment:
|
Second Mortgage:
|
| Third Mortgage:
|
|
|
| Are real estate taxes included in your mortgage payment?
Yes
No |
| Is home owner's insurance included in your mortgage payment?
Yes
No |
| Taxes not included in house payment or your mortgage payment? |
| Utilities (Normal Monthly Average): |
|
| Electricity and Gas:
|
Water:
|
Telephone (land line):
|
| Trash Pick-Up:
|
|
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| Basic Needs: |
|
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| Home Maintenance (home owners):
|
Food (Monthly):
|
Clothing (Monthly):
|
| Laundry, Dry Cleaning, Soap, Etc:
|
Medical Expense not paid by insurance:
|
|
| Transportation: |
|
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| Gasoline/Auto Maintenance:
|
|
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| Insurance: |
|
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| Renters/Homeowner Insurance:
|
Life Insurance (other than employer):
|
Health Insurance (other than employer):
|
| Automobile Insurance:
|
Other Insurance:
|
|
| Taxes: |
|
|
| Are any other taxes deducted from your wages?
Yes
No |
| If so, what type of taxes are they? |
| Other Expenses: |
|
|
| Alimony or Child Support:
|
Payments for someone outside home:
|
Cable or internet:
|
| Lease Payments:
|
Child Care Expenses:
|
Babysitter/Day Care Expenses:
|
| School Expenses:
|
College Tuition (not loans):
|
Student Loan Repayment:
|
| Cell Phone:
|
Other:
|
Other:
|
| Charitable Giving (if claimed on taxes):
|
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| Use the space below to describe any additional monthly expenses that you must pay out of pocket that are not covered here. Explain the type of expense,
amount of expense, and how long you will continue to have this expense. |
|
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YOUR MOTOR VEHICLES |
Motor vehicles include cars, trucks, SUV's, motorcycles, mobile homes, boats, trailers, campers, etc. that are
TITLED IN YOU (OR YOUR SPOUSE'S NAME). |
| Do you have any motor vehicles?
Yes (Complete This Section)
No (Skip This Section) |
| Type:
Automobile
Truck
Motorcycle
Mobile Home
Other |
Year:
|
Make:
|
Model:
|
| Condition:
Excellent
Good
Fair
Poor
Not Running |
Mileage:
|
| Name(s) on vehicle title: |
| Is vehicle leased?
Yes
No |
If yes, what is the "buy out" on the lease? |
| Name of company you make payments to for this vehicle: |
| Address: |
City:
|
State:
|
Zip Code: |
| Account Number: |
Date Established Loan: |
|
|
| Monthly Payments: |
Months Behind in Payments (#): |
|
|
|
|
| What is the "pay off" amount on vehicle: |
Check One:
Keep
Surrender |
| Have you gone to a loan company and listed this vehicle as collateral for a personal loan?
Yes
No |
| If so, what is the name of the loan company for personal loan:
|
|
| Type:
Automobile
Truck
Motorcycle
Mobile Home
Other |
Year:
|
Make:
|
Model:
|
| Condition:
Excellent
Good
Fair
Poor
Not Running |
Mileage:
|
| Name(s) on vehicle title:
|
| Is vehicle leased?
Yes
No |
If yes, what is the "buy out" on the lease?
|
| Name of company you make payments to for this vehicle:
|
| Address:
|
City:
|
State:
|
Zip Code:
|
| Account Number: |
Date Established Loan: |
|
|
| Monthly Payments: |
Months Behind in Payments (#): |
|
|
|
|
| What is the "pay off" amount on vehicle:
|
Check One:
Keep
Surrender |
| Have you went to a loan company and listed this vehicle as collateral for a personal loan?
Yes
No |
| If so, what is the name of the loan company for personal loan:
|
|
| Do you have more than two vehicles? |
Yes
No |
|
| If more than two vehicles, please bring all information with you to consultation. |
| |
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|
YOUR REAL ESTATE |
| Do you have any real estate?
Yes (Complete This Section)
No (Skip This Section) |
| Check the type of real estate you own:
House
Condominium
Vacant Lot
Other |
| Name(s) on Deed or Title: |
| Address of Real Estate: |
| Name of Mortgage Company: |
| Address: |
City:
|
State:
|
Zip Code: |
| Account Number:
|
Date obtained this mortgage:
|
| Monthly Payments:
|
What is the "pay off" amount on this mortgage?
|
| Are you behind in payments?
Yes
No If so, what months?
|
| What interest rate do you pay? |
Amount to catch up back payments? |
| What year was your real estate last appraised? |
|
| What was the appraised value? |
|
| Is this mortgage in the process of foreclosure?
Yes
No Intention:
Keep
Surrender |
| Do you have a second mortgage on the real estate?
Yes
No |
|
| Do you have more than one piece of real estate?
Yes
No |
| If more than one peace of real estate, please bring all information to consultation. If in foreclosure, please provide a copy of the court
documents you were served. |
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SECOND MORTGAGE INFORMATION (IF APPLICABLE) |
| Name of Mortgage Company:
|
| Address:
|
City:
|
State:
|
Zip Code:
|
| Account Number:
|
Date obtained this mortgage:
|
| Monthly Payments:
|
What is the "pay off" amount on this mortgage?
|
| Are you behind in payments?
Yes
No If so, what months?
|
| What interest rate do you pay?
|
Amount to catch up back payments?
|
| What year was your real estate last appraised?
|
|
| What was the appraised value?
|
|
| Is this mortgage in the process of foreclosure?
Yes
No Intention:
Keep
Surrender |
| Do you have a third mortgage on the real estate?
Yes
No |
|
| If you have a third mortgage on the real estate, please bring all information to consultation. |
| |
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|
CREDITORS |
Please bring all communications from creditors received in the last 60 days, including statements, bills, collection letters, lawsuit,
foreclosure notices, etc. |
| Creditor 1 |
Type of Debt |
Balance |
| Creditor 2 |
Type of Debt |
Balance |
| Creditor 3 |
Type of Debt |
Balance |
| Creditor 4 |
Type of Debt |
Balance |
| Creditor 5 |
Type of Debt |
Balance |
| Creditor 6 |
Type of Debt |
Balance |
| Creditor 7 |
Type of Debt |
Balance |
| Creditor 8 |
Type of Debt |
Balance |
| Creditor 9 |
Type of Debt |
Balance |
| Creditor 10 |
Type of Debt |
Balance |
| Creditor 11
|
Type of Debt
|
Balance
|
| Creditor 12
|
Type of Debt
|
Balance
|
| Creditor 13
|
Type of Debt
|
Balance
|
| Creditor 14
|
Type of Debt
|
Balance
|
| Creditor 15
|
Type of Debt
|
Balance
|
| Creditor 16
|
Type of Debt
|
Balance
|
| Creditor 17
|
Type of Debt
|
Balance
|
| Creditor 18
|
Type of Debt
|
Balance
|
| Creditor 19
|
Type of Debt
|
Balance
|
| Creditor 20
|
Type of Debt
|
Balance
|
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|
|
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