American Bankruptcy

Online Submission Questionnaire

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Questions?
Email: American Bankruptcy

NOTE!
We prepare all documents using the forms mandated by the new Bankruptcy Reform Act of 2005, and subsequent modifications.

Are you being harassed? ...Facing repossessions or foreclosure?
Use our Priority FILING OPTION to stop them dead in their tracks!
Just check and select the Priority FILING OPTION in our information submission form and we will prepare and forward your petition ready for you to sign and file with the bankruptcy court within 24 to 48 hours of receipt of your submission and verified payment.

Note!
Your bankruptcy Schedules will be sent to you in Acrobat Reader (pdf.) downloadable format for your examination and approval. You will need Acrobat Reader to open, read, and print out your documents.
Your completed petition and all necessary forms required to be "live" signed/certified by us will be sent to you by USPS First-Class or Priority Mail per your choice of our standard or Priority preparation service. 		Acrobat Reader is available free to the public.If you don't already have Acrobat Reader installed on your computer,

just click on the Acrobat Reader icon above to download and install it on your computer.

If you have any questions that we haven't answered here in this website regarding the preparation and filing of a Chapter 7 personal bankruptcy petition please:

email us: American Bankruptcy
We will be here with email support for you throughout the process.

LEGAL NOTICE:

NOTICE TO DEBTOR BY NON-ATTORNEY BANKRUPTCY PETITION PREPARER

I am a bankruptcy petition preparer. I am not an attorney and may not practice law or give legal advice. Before preparing any document for filing as defined in § 110(a)(2) of the Bankruptcy Code or accepting any fees, I am required by law to provide you with this notice concerning bankruptcy petition preparers.

Under the law, § 110 of the Bankruptcy Code (11 U.S.C. § 110), I am forbidden to offer you any legal advice, including advice about any of the following:

  • whether to file a petition under the Bankruptcy Code (11 U.S.C. § 101 et seq.);
  • whether commencing a case under chapter 7, 11, 12, or 13 is appropriate;
  • whether your debts will be eliminated or discharged in a case under the Bankruptcy Code;
  • whether you will be able to retain your home, car, or other property after commencing a case under the Bankruptcy Code;
  • concerning the tax consequences of a case brought under the Bankruptcy Code;
  • concerning the dischargeability of tax claims;
  • whether you may or should promise to repay debts to a creditor or enter into a reaffirmation agreement with a creditor to reaffirm a debt;
  • concerning how to characterize the nature of your interests in property or your debts; or
  • concerning bankruptcy procedures and rights.

In addition, under 11 U.S.C. § 110(h), the Supreme Court or the Judicial Conference of the United States may promulgate rules or guidelines setting a maximum allowable fee chargeable by a bankruptcy petition preparer. As required by law, I have notified you of the maximum amount, if any, before preparing any document for filing or accepting any fee from you.

SUBMISSION TIPS:

This questionnaire is designed so it can be filled out in your browser and submitted to us through the SECURE online submission script on our server by simply completing the form online, inputing your email address, then clicking on the "SUBMIT ORDER NOW" button at the end of the form. Don't let the size of the form intimidate you. The vast majority of our clients don't use more than 20% of the form. Just leave any portion that doesn't apply to you BLANK.

Helpful hints:

1.    You can logon to this page at our website, then sign off your Internet Service Provider (i.e., AOL, Juno, direct dial-up, etc.), and complete the form while you are offline. Be sure not to close your browser until after you complete the form and get it ready to submit to us. When you have completed the form offline, just sign on to your ISP again and click the "SUBMIT ORDER NOW" button at the end of the form. The information in the form will be "SECURELY" transmitted to us through our online script. If you submit the form through our SECURE online submission script, you won't have to worry about overflow text in the text boxes, as the online submission method allows us to access all of the overflow text in the text boxes.

Preparing it in advance by hand can help to expedite your work when you are ready to complete and submit the form to us online. The form will print out on approximately 25 pages, depending on your system settings.

The current filing fees for most bankruptcy districts, for a Chapter 7, which you will have to forward directly to the clerk of the bankruptcy court along with your completed documents will be $299.00. You can submit your petition in person, by courier, or by mail.

Within 180 days prior to filing a personal bankruptcy petition, all personal bankruptcy filers will have to undergo a credit counseling session with a counseling agency approved by the U.S. Trustee. (There are exceptions where there is an emergency and the person could not receive counseling within five days, or where the U.S. Trustee has determined that the approved agencies are not adequate to provide the required counseling.) If a debt management plan is developed it must be filed with the court whether you find it acceptable or not. Joint filers must BOTH undergo the counseling session.

If you have not undergone a counseling session yet, you can CLICK HERE for a state-by-state listing of U.S. Trustee approved credit counseling agencies throughout the United States. Counseling services vary, with Internet, telephonic, and face-to-face sessions available.

Most people are called upon to make only one personal appearance during the course of the Chapter 7 bankruptcy process. That is 20 to 40 days after your submission to the court clerk, when a meeting of creditors is scheduled (This is sometimes called a "341 meeting"). The vast majority of creditors do not put in an appearance at the meeting. Normally you will be asked a few routine questions by the bankruptcy trustee appointed to your case by the court. The final discharge of your debts usually takes place in two to four months from the day of your filing the petition, depending upon the case load of your local bankruptcy court.

Be sure to indicate on the following submission form if you intend to keep your house, condo, automobile, or any other possession on which you still owe money. If you still owe money on any item you want to keep, be sure to keep making the payments on those particular items.

Immediately upon filing the petition, all creditors, including the IRS, are stayed (stopped, prohibited) from any further collection activities. Under some strictly defined conditions, even back taxes owed to the IRS can be eliminated in Chapter 7 bankruptcy, so don't forget to include all you can about any back taxes the IRS claims you owe them. The court will notify all the creditors that you list in your petition.

Chapter 7 filers may convert their filing to a Chapter 13 anytime before the conclusion of their case. The permission of the court must be obtained, by filing a motion for conversion.

Don't let the length of the questionnaire discourage you. Remember: If a question doesn't apply to your circumstances, just leave the the answer area BLANK. When you are asked to put a value on your personal possessions, just put down what you think you could get at a garage or yard sale for any particular item. Most of us have a pretty good idea what the approximate value of our home is, but if you really don't, contact a Realtor and ask for what is called a"CMA" (that is a Comparative Market Analysis). Realtors don't customarily charge for a CMA, if they think they have a chance to get a listing to sell the property. A CMA will give you a reasonable approximation of the value of your home. Just answer the questions to the best of your ability then submit the questionnaire to us. If we have any questions while we are preparing your petition, we will contact you by email, and we can deal with them at that time.

Remember, as soon as you get the Chapter 7 petition filed you should stop making payments on any debt that you have petitioned the court to have discharged (avoided, eliminated). In Chapter 7 filings, you must keep making the payments on your house and vehicle, if you intend to keep them and reaffirm those debts.

NOTE!
The bankruptcy court (venue) where you must file your personal bankruptcy petition is determined by the state and COUNTY in which you have resided for the greater portion of the 180 days (91 days)immediately preceding the date of your filing. In the case of military personnel stationed overseas, it is the state and COUNTY in which you claim your residence of record.

If you haven't lived in your current state for at least 2 years prior to the anticipated date of your filing, you may have to use the exemption laws for the state where you were living before that 2 year period began. However, if the state wherein you are required to file your return, as determined by the residency requirements stated above, allows you to choose to use the federal exemptions, you may use the federal exemptions regardless of how long you lived in that state.

CLICK HERE to open, read, download, or print any state or federal exemption statutes.

The following fees cover our Chapter 7 preparation services. All fees are in US Dollars.
Filing Status Standard Chapter 7 Priority Chapter 7
Everyone $99.95 $124.95
FYI: We do NOT prepare bankruptcy documents for residents of the following states and/or federal judicial districts.
  • Arizona
  • North Carolina
  • South Carolina
  • Texas
  • Colorado
  • Ohio

Bankruptcy Questionnaire

Printing this form from your browser will allow you to prepare it by hand. Preparing it in advance by hand will help expedite your work when you are ready to submit the form to us online. The form will print out on approximately 30 pages, depending on your system settings.

You can also prepare it in advance in your browser while offline by saving this page to a file on your computer, then opening it offline and prepare it in advance. You can then print out the form and use it to assist you in filling out the form online. If you close the browser with input data, the data will not be saved, only the form.

This questionnaire is designed to be filled out online, in your browser, and submitted to us through our SECURE online submission script.

If you have decided that debt relief through bankruptcy, and a financial fresh start, is the best choice for you; we will then use the information you provide to us in this submission form to prepare the required paperwork. We will return the required paperwork to you by email, First-Class Mail, and/or Priority Mail, per your choice, based upon your selection of service. Upon receipt of your completed petition, you can sign the petition and print out as many copies of the documents as your court tells you to file.

We recommend that you prepare an extra copy and forward it to the clerk of the court along with the required number of copies. Include a note and a self-addressed, stamped envelope and request that a "conformed copy" be returned to you. This way you will have a date and time-stamped copy of your petition without having to acquire one later from the court. This may come in handy to discourage any creditors who may continue to harass you until they receive notice of your filing from the bankruptcy court.

Average completion time is 1-2 hours. There will be entire sections that do not apply to your circumstances. Simply leave blank all questions that do not apply.

If you run out of room for creditors in any category, just list them in a separate email and send them to us. Be sure to mention that you have submitted the form and include your name and email address.


Bankruptcy Input Info
Note!

This is a large form. Depending upon your browser settings, some browsers may time-out before the form has completely downloaded. Scroll to the end of the form and verify that the "Submit Order Now" button is visible. If it is not visible, hold down your "control" key and click on the "refresh" button at the top of your browser for a "forced reload" of the form.

Use the "TAB" key or a mouse click to move from textbox to textbox while filling-out the form. Inadvertently using the "ENTER" key to move from textbox to textbox, before you input your contact email address near the end of the form, may produce an "error" message instructing you to input your contact "email" address. If you inadvertently hit the "ENTER" key just use the "back" button at the top of your browser to return to the form and resume your work.

Select The Preparation Service You Want:

Payment Options, Check just One:
I will pay court fees in full with filing of petition   
I want to pay court fees in 4 installments,
if the court in my jurisdiction allows it.   

Soc.Sec.No.:
Date of Birth: (format:xx/xx/xxxx)
FULL NAME(first/middle/last)
 Other names used in last 8 years (maiden, married, trade name,etc.)
Does the Debtor own or have possession of any property that poses, or is alleged to pose, a threat of imminent and identifiable harm to public health or safety?
Yes:     No:
If yes, describe: 		I/we have received, or intend to receive, budget and credit counseling, as required by the Bankruptcy Reform Act of 2005, during the 180-day period immediately preceding the filing of my/our petition.

If you have already received your credit couseling, provide the name and mailing address of the agency that provided your certificate.
Amount you paid:

YOUR ADDRESS: YOUR CITY
YOUR County (Not Country) YOUR STATE   YOUR ZIP
YOUR Current Mailing address, if different:

If you have resided in your current state for less than 2 years, what was your previous state of residence?  

Have you resided at your current address for less than 91 days?
  Check one:   Yes      No

 YOUR Phone number:
List Any Prior Bankruptcy case filed within the last 8 years:
Provide mailing address of court, case number of previous bankruptcy, and the date the previous bankruptcy was filed.
SELECT MARITAL STATUS:  
Dependents of Debtor


    Age Relationship

    Age Relationship

    Age Relationship

    Age Relationship
Dependents of Debtor


    Age Relationship

    Age Relationship
YOUR SPOUSE:
Is Spouse filing as Joint Debtor?Yes     No
If Yes Then: Spouse's Full Name(first/middle/last)
   SSN 
Date of Birth: (format:xx/xx/xxxx)
Address 
City  State  Zip  		Spouse's other names used in last 8 years (maiden, married, trade names, etc.)
Spouse's mailing address if different from above:
 NATURE OF DEBT:
Personal      Business
Type of business (if applicable):
Indicate Debtor's interest in any real estate or personal property (mobile home, RV, etc.) used as your primary residence.
(How it is owned):
For property ownership select Debtor Only, Husband, Wife,
Joint, or Community:

Primary residence of debtor:
Address:

Current Payoff, include arrearages and all legal/foreclosure fees, if any:
First Mortgage 
2nd Mortgage 
3rd Mortgage 
 Current Value:

Owned by:    

Complete Name and Mailing Address
of Mortgage Holder:

Date Property was purchased/acquired:
(format:xx/xx/xxxx)

Account#    

I/we want to claim my/our primary residence as my/our homestead and protect it with any homestead exemption available to me/us:
Yes      No  

Indicate Debtor's interest in any other real estate
(How it is owned):
For property ownership select Husband, Wife, Joint, or Community:
REAL ESTATE PROPERTY - ONLY IF OWNED OR BUYING:
Other Real Estate of debtor:
Address:

Current Payoff: 
Current Value:

Owned by:    

Complete Name and Mailing Address
of Mortgage Holder:

account#    

DEBTOR'S EMPLOYMENT
* Neither you nor you spouse are required to send check stubs, etc., to us, to verify income information 		SPOUSE'S EMPLOYMENT
Your Occupation:
Employer Name and Address:

How long employed?    		Spouse's Occupation: 
Name and Address of Spouse's Employer:

How long employed?   
MONTHLY INCOME: Use the average income for the past 6 months (Last 6 months TOTAL gross income divided by 6 = average MONTHLY gross income).
*You are not required to send receipts for expenses with this form.
If you are married and filing as an individual, you should include spousal income (if any), if your spouse is living with you and paying a portion of the monthly living expenses.
Average Monthly Income Yours Spouse
1. Average gross wages, salary, commissions (before deductions)
2. Estimated average monthly overtime
3. Subtotal of Income( 1 & 2 above) =
Payroll Deductions Yours Spouse
4. Average payroll taxes & Social Security
5. Average insurance deduction
6. Average union dues
7. Other (specify)
9. Subtotal of 4-7 above
10. TOTAL Average Net Monthly Income (#3 - #9)
Other Income Yours Spouse
11. Average regular income from business, farm or profession
12. Average monthly income from real estate property
13. Average monthly interest Dividends
14. Average alimony or support payments received by debtor, Spouse, or dependents
15. Social Security or other government benefits (Specify)
16. Average Monthly Private Pension and/or Retirement Income
17. Other Income (specify)
18. Subtotal of other income (11-17 above)
19. TOTAL AVERAGE MONTHLY INCOME ( 10 + 18 above)

MONTHLY EXPENSES
Monthly Expenses
*The separate "spouse" column is for use only when spouse is filing jointly but maintains a separate primary residence.		 Debtor *Spouse Both
Rent or mortgage paid monthly
Are real estate taxes included in monthly mortgage payment? Yes No Yes No Yes No
Is insurance included in monthly mortgage payment? Yes No Yes No Yes No
Electricity
Heating Fuel
Water & Sewer
Telephone
Cable television Service
Other (specify)
Home Repair & upkeep
Food
Clothing
Laundry & dry cleaning
Medical & Dental
Transportation (do not include car payments)
Recreation (newspapers, magazines, entertainment, clubs
Charitable contributions (specify)
Insurance (not deducted from earnings or included in mortgage) Debtor Spouse Both
Homeowners or Renters Insurance
Life insurance
Auto Insurance
Other (specify)
Taxes not deducted from wages or included in mortgage (specify)
MONTHLY Installment Payments (not listed above)on SECURED items, such as vehicle, furniture, or other items which are pledged as security for a debt that you want to keep after bankruptcy.

Be sure to also list the estimated value and total amount still owing on any items mentioned here in the section SECURED DEBTS and indicate that you want to keep the item and continue making the payments.
NOTE!
Do NOT list UNSECURED debts such as gas cards or credit cards here. List them in the UNSECURED section below.

 Debtor Spouse Both
Auto- Year/Make/Model:
Auto - Year/Make/Model:
Creditor Name and Mailing Address:  Acct#: 
Creditor Name and Mailing Address:  Acct#: 
Creditor Name and Mailing Address:  Acct#: 
Creditor Name and Mailing Address:  Acct#: 
Creditor Name and Mailing Address:  Acct#: 

 

PERSONAL PROPERTY For purposes of valuing your property for bankruptcy - give garage/yard sale values, not what you originally paid, or what you still owe.
* If you are married or someone else has an ownership interest in your property; Identify your interest in the property (how it is owned), i.e., H = husband, W = wife, J = Joint, C=community property
Property Type Description Estimated
Value		 H W J C
Cash On Hand H W J C
Checking, savings,
CD's, stocks, etc.
Select Type Here: 		Account#

Name and Mailing Address of Bank, Brokerage, etc:
 H W J C
Checking, savings,
CD's, stocks, etc.
Select Type Here: 		Account#

Name and Mailing Address of Bank, Brokerage, etc:
 H W J C
Security deposits
(utility/landlord etc.)
Select Type Here: 		Name and Mailing Address
of Deposit holder:
 H  W  J  C 
Security deposits
(utility/landlord etc.)
Select Type Here: 		Name and Mailing Address
of Deposit holder:
 H  W  J  C 
Household Goods & Furnishings Description Value H W J C
Living room furnishings H  W  J  C 
Den/family room H  W  J  C 
Computer equipment H  W  J  C 
Stereo & audio H  W  J  C 
Television(s) H  W  J  C 
VCR(s) H  W  J  C 
desks, bookcases etc. H  W  J  C 
1st bedroom H  W  J  C 
2nd bedroom H  W  J  C 
3rd bedroom H  W  J  C 
Kitchen dinette H  W  J  C 
Dining Room H  W  J  C 
Refrigerator H  W  J  C 
Cooking stove H  W  J  C 
Dishwasher (not built-in) H  W  J  C 
Microwave H  W  J  C 
Minor appliances H  W  J  C 
Washer/dryer H  W  J  C 
Misc.Other H  W  J  C 
Personal PropertyDescriptionValueHWJC
books, art, antiques H  W  J  C 
stamp/coin/record/CD collections H  W  J  C 
Wearing apparel H  W  J  C 
Fur & Jewelry H  W  J  C 
firearms, sports, hobby H  W  J  C 
Surrender value in insurance policies (How much could you borrow against your life or annuity policy right now?). Name and Mailing Address of Provider:

Policy # 
 H  W  J  C 
annuities Name and Mailing Address of Provider:

Policy # 
 H  W  J  C 
IRA, ERISA, KEOGH etc. Name and Mailing Address of Provider:

I.D. # 
 H  W  J  C 
stock, interests in corp./business List specific interests:
 H  W  J  C 
interests in partnerships, joint ventures List specific interests:
 H  W  J  C 
government & corporate bonds, negotiable/non-negotiable instruments List specific interests:
 H  W  J  C 
accounts receivable
(Individuals and joint filers include estimated accrued tax overpayments that you anticipate you will be refunded when you file your tax returns.)		 List specific interests:
 H  W  J  C 
alimony, support, property settlement List specific interests:
 H  W  J  C 
other liquidated debts owing to debtor List specific interests:
 H  W  J  C 
equitable or future interests in life estates List specific interests:
 H  W  J  C 
interests in estate of decedent List specific interests:
 H  W  J  C 
contingent unliquidated claims List specific interests:
 H  W  J  C 
patents/copyright, intellectual property List specific interests:
 H  W  J  C 
licenses, franchises, general intangibles List specific interests:
 H  W  J  C 
Auto(s) List Make, Model, and Lien Holder
for each auto:
 H  W  J  C 
boats, motors, etc. List Specific Interests:
 H  W  J  C 
Office/Business/Farm Description Value H W J C
office equip./furnishings List Specific Interests:
 H  W  J  C 
machinery/fixtures, equipment/supplies List Specific Interests:
 H  W  J  C 
inventory List Specific Interests:
 H  W  J  C 
animals (For Commercial Purposes Only) List Specific Interests:
 H  W  J  C 
crops, growing or harvested List Specific Interests:
 H  W  J  C 
farm equip/implements List Specific Interests:
 H  W  J  C 
farm supplies, chemicals & feed List Specific Interests:
 H  W  J  C 
other personal property not listed elsewhere List Specific Interests:
 H  W  J  C 

 

SECURED CREDITORS (Any debt secured with collateral, such as, vehicle, furniture, appliances, boats, RV's, etc.)
Creditor Name and
Mailing Address:
 Collateral Date
(mo/yr)
incurred		 Intend to keep
Collateral &
continue payments?		 Balance
Owed		 Collateral
Value
Now

Act#:  Nature of Lien: Check One
Purchase Money  
Non-Purchase Money   		Intend to keep
Collateral &
continue payments?
Yes   No 

Act#:  Nature of Lien: Check One
Purchase Money  
Non-Purchase Money   		Intend to keep
Collateral &
continue payments?
Yes   No 

Act#:  Nature of Lien: Check One
Purchase Money  
Non-Purchase Money   		Intend to keep
Collateral &
continue payments?
Yes   No 

Act#:  Nature of Lien: Check One
Purchase Money  
Non-Purchase Money   		Intend to keep
Collateral &
continue payments?
Yes   No 

Act#:  Nature of Lien: Check One
Purchase Money  
Non-Purchase Money   		Intend to keep
Collateral &
continue payments?
Yes   No 

Act#:  Nature of Lien: Check One
Purchase Money  
Non-Purchase Money   		Intend to keep
Collateral &
continue payments?
Yes   No 

PRIORITY DEBTS (IRS, state and local taxes etc.; include penalties)
Creditor &
Address:		 Type of debt Date
(mo/yr)
incurred		 Acct.# Balance
Owed

Type of Priority:

Type of Priority:

Type of Priority:

Type of Priority:

UN-SECURED DEBTS (credit cards, medical, personal loans, NSF checks, etc.)
There is room in each creditor address textbox to type 2 or 3 addresses. So you may add 1 or 2 collection agencies to each original creditor, if necessary.
Creditor &
Address:		 Type of Debt Date
(mo/yr)
incurred		 Acct.# Balance
Owed

Unexpired Leases and Contracts
List below any lease or contracts that are still current that you are party to. Include residential, car and business leases, and service or business contracts.

Nature and Description of Contract Name and Address of Other Party or Parties Date that Contract Expires
Description of Lease
 Name and Mailing Address of Other Party
 		 Date of Lease Expiration
Mo/Yr
Description of Lease
 Name and Mailing Address of Other Party
 		 Date of Lease Expiration
Mo/Yr
Description of Lease
 Name and Mailing Address of Other Party
 		 Date of Lease Expiration
Mo/Yr

DEBTORS' ANNUAL INCOME
January 1, this year, to Date of Filing 
 Last year 
 Year before last 
SPOUSES ANNUAL INCOME
(If spouse is filing jointly and has income)
January 1, this year, to Date of Filing 
 Last year 
 Year before last 

Payments over $600 to any one creditor within the last 90 days
Creditor Acct. # Date of payment(s)
(mo/day/yr)		 Amount Paid Balance
Name and Mailing Address of Creditor
 Account #
 Date of Payments

mo/day/year		 Amount Paid
 Balance Owing
Name and Mailing Address of Creditor
 Account #
 Date of Payments

mo/day/year		 Amount Paid
 Balance Owing
Name and Mailing Address of Creditor
 Account #
 Date of Payments

mo/day/year		 Amount Paid
 Balance Owing

Repossessions, Attachments, Garnishments, Seizures, Foreclosures.
List only 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 day you intend to file your documents with the bankruptcy court.
Creditor Acct.# Date (mo/yr) Property type Value
Name and Mailing Address
Of Creditor
 Account#
 Date
 PropertyType
 Value
Name and Mailing Address
Of Creditor
 Account#
 Date
 PropertyType
 Value
Name and Mailing Address
Of Creditor
 Account#
 Date
 PropertyType
 Value

Law suits in which debtor was or is a party within the last 1 year
Names of parties Case #, County/State Court Type of suit Complete?
Names of Parties
 Case#, County/State
 Court
(Civil, Superior, District, Etc.)
 Type of Suit
(Civil, Marital, Custodial, Etc.)
 Complete? 
Pending?    
Names of Parties
 Case#, County/State
 Court
(Civil, Superior, District, Etc.)
 Type of Suit
(Civil, Marital, Custodial, Etc.)
 Complete? 
Pending?    
Names of Parties
 Case#, County/State
 Court
(Civil, Superior, District, Etc.)
 Type of Suit
(Civil, Marital, Custodial, Etc.)
 Complete? 
Pending?    

Set Offs (by creditor, bank, etc. against debtor in the last 90 days.
Set Off; Definition: When a creditor confiscates an asset (i.e., deposit, savings, cash, CD, bond, etc.) and applies the value of the asset against the outstanding balance on a debt.
Creditor Date (mo/yr) Acct.# Amount
Name and Mailing Address
 Date of Action (mo/yr)
 Account #
 Amount of Set Off
Name and Mailing Address
 Date of Action (mo/yr)
 Account #
 Amount of Set Off

Closed Financial Accounts
Name of Institution Date of Closing(mo/yr) Account# Balance At Closing
Name and Mailing Address
 Date of Closing (mo/yr)
 Account #
 Balance At Closing
Name and Mailing Address
 Date of Closing (mo/yr)
 Account #
 Balance At Closing
Name and Mailing Address
 Date of Closing (mo/yr)
 Account #
 Balance At Closing

Current Safe Deposit Box (belonging to debtor(s)
Institution Contents
Name and Mailing Address
of Institution
 Contents
of Box
Name and Mailing Address
of Institution
 Contents
of Box

Charitable Contributions or Gifts Over $200 - (within the last 12 months)
Person/Group & address Date (mo/yr) Value Nature of Gift
cash, clothing, etc.)
Name and Mailing Address of
Person or Group
 Date (mo/yr)
 Value of Gift(s)
 Nature of Gift
(cash, clothing, etc.)
Name and Mailing Address of
Person or Group
 Date (mo/yr)
 Value of Gift(s)
 Nature of Gift
(cash, clothing, etc.)
Name and Mailing Address of
Person or Group
 Date (mo/yr)
 Value of Gift(s)
 Nature of Gift
(cash, clothing, etc.)

Other Property Transfers (within 1 yr)
Person/Group & address Date (mo/yr) Value Type of Property
Name and Mailing Address of
Person or Group
 Date (mo/yr)
 Value of Property(s)
 Nature of Property
(cash, clothing, etc.)
Name and Mailing Address of
Person or Group
 Date (mo/yr)
 Value of Property
 Nature of Property
(cash, clothing, etc.)
Name and Mailing Address of
Person or Group
 Date (mo/yr)
 Value of Property(s)
 Nature of Property
(cash, clothing, etc.)

Losses from fire, theft, gambling etc. within 1 year
Description of Property Date (mo/yr) Circumstances Value of Loss
Description of Property
 Date (mo/yr)
 Circumstances
 Value of Loss
Description of Property
 Date (mo/yr)
 Circumstances
 Value of Loss

Property Held for another person
Owner's Name/Address Description of Property Location of Property Value
Owners Name and Address
 Description of Property
 Location of Property
 Value
Owners Name and Address
 Description of Property
 Location of Property
 Value

The following information is ONLY for debtor's who HAVE BEEN IN BUSINESS within THE LAST 2 YEARS

Debtor's Business Interests
Name of Business & Address Nature of Business Debtor's interest Date Closed
Name of Business and Address
 Nature of Business
 Debtor's Interest
 Date Closed
Name of Business and Address
 Nature of Business
 Debtor's Interest
 Date Closed

Books, Records, and Financial Statements

bookkeepers/accountants within the last 6 years
Name of Bookkeeper/Accountant & Address Dates of Service
Name of Bookkeeper/Accountant & Address
 Dates of Service (From: To)
Name of Bookkeeper/Accountant & Address
 Dates of Service (From: To)

Persons or firms who have prepared a financial statement or conducted an audit within the last 2 years
Name of Individual or firm & Address Dates of Service
Name of Bookkeeper/Accountant & Address
 Dates of Service (From: To)
Name of Bookkeeper/Accountant & Address
 Dates of Service (From: To)

Persons or Firms in Possession of Records/Books
Name of Person or Firm & Address Dates of Service
Name of Person or Firm & Address
 Dates of Service
Name of Person or Firm & Address
 Dates of Service

Financial institutions, creditors, or others to whom financial statement was issued within the last 2 years
Name of Person or Entity & Address Date Issued
Name of Person or Firm & Address
 Dates of Issuance
Name of Person or Firm & Address
 Dates of Issuance

Inventories

Last 2 Inventories
Person Supervising Date Value of Inventory
cost, market, other
Name of Person or Firm & Address
 Date of Inventory
 Value of Inventory
(cost, market, other)
Name of Person or Firm & Address
 Date of Inventory
 Value of Inventory
(cost, market, other)

Person in possession of inventory records
Name of Person & Address Dates of Inventory
Name of Person or Firm & Address
 Dates of Inventory
Name of Person or Firm & Address
 Dates of Inventory

Comments/Requests/Special Instructions.

Your documents, ready to be copied, signed, and mailed for filing to your local bankruptcy clerk, will be returned to you within 5 to 7 working days of receipt of the completed questionnaire and verified payment, for clients requesting standard handling.
For clients requesting Priority handling, your petition will be forwarded to you within 24 to 48 hours of receipt of the completed questionnaire and verified payment.


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NOTE!
If you are forwarding this form by mail, make checks or money orders payable to "Gordon L. Gooch" and mail to:.
American Bankruptcy
Attn: Gordon L. Gooch
POB 298
Cherokee Village, AR 72525

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