Fill and Sign the 369 G Form

County Court __________________________ County, Colorado Court Address: Plaintiff(s)/Petitioner(s): v. Defendant(s)/Respondent(s): COURT USE ONLY Attorney or Party Without Attorney (Name and Address): Phone Number: E-mail: FAX Number: Atty. Reg. #: Case Number: Division Courtroom PATTERN INTERROGATORIES UNDER C.R.C.P. 369(g) - INDIVIDUAL The following Pattern Interrogatories are propounded to __________________________________ (name of Judgment Debtor) pursuant to C.R.C.P. 369(g). Answer all of the questions and each and every part thereof fully and completely. Your answers must be filed with the Court and a copy mailed to the sender no later than 14 days after you receive them. Use a separate sheet of paper, if necessary. Do not use Post Office boxes for any address provided in your answers unless you request and receive permission from the Court. 1. State your home address, business address, home phone, business phone, and date of birth: Home address: __________________________________________________________________________ Business address: ________________________________________________________________________ Home phone: _______________________________ Business phone: ______________________________ Date of Birth: ____________________________ 2. If you are employed, state the name, address, and phone number of your employer(s). If more than one employer show additional employers on a separate sheet of paper. Name of Employer: ________________________________________ Phone Number: _________________ Address: _______________________________________________________________________________ 3. If you have any income from any source other than your employer (for example, rental income, commissions, stock dividends, interest), state the name, address, phone number, amount of income, and dates of payment of the person or business paying you the income. Name of Payor: _________________________________________ Phone Number: ___________________ Address: _______________________________________________________________________________ Amount of Payments: ______________________________ Dates of Payments: ______________________ Name of Payor: _________________________________________ Phone Number: ___________________ Address: _______________________________________________________________________________ Amount of Payments: _____________________________ Dates of Payments: _______________________ 4. If you are not employed or have other sources of income, state all sources of money you use to pay your living expenses, including the name, address, telephone number, and amounts. Show additional sources on a separate sheet of paper, if necessary: FORM 7 JDF 105CS R1-18 PATTERN INTERROGATORIES UNDER C.R.C.P. 369(g) - INDIVIDUAL Page 1 of 5 Name of Payor: _________________________________________ Phone Number: ___________________ Address: _______________________________________________________________________________ Amount of Payments: $____________________________ Dates of Payments: _______________________ Name of Payor: _________________________________________ Phone Number: ___________________ Address: _______________________________________________________________________________ Amount of Payments: $____________________________ Dates of Payments: _______________________ 5. State whether you own or rent the home you live in, including the amount of rent or house payments you make:  Rent _________________ (monthly rent payment)  Own _________________ (monthly house payment) Name(s) of Owner(s): _____________________________________________________________________ 6. State the name, address, account number and type of account for every financial institution (bank, savings and loan, credit union, brokerage house) where you have an account or where you have signature authority on the account. Provide additional information on a separate sheet of paper, if necessary. Name: _______________________________________________ Address: _______________________________________________________________________________ Type of Account: _____________________________ Account Number (last 4-digits): _______________ Name: _______________________________________________ Address: _______________________________________________________________________________ Type of Account: _____________________________ Account Number (last 4-digits): _______________ Name: _______________________________________________ Address: _______________________________________________________________________________ Type of Account: _____________________________ Account Number (last 4-digits): _______________ 7. If you own or owned during the last four years, or regularly use any automobiles, motorcycles, trucks, RV’s, ATV’s, Jet skis, boats, or trailers, list the make, model, year, VIN, date of purchase, purchase price, name of owner if only used by you. If you no longer own the vehicle, identify date of sale, sale price, and name and address of purchaser. Provide additional information on a separate sheet of paper, if necessary. Make: ________________ Model: _____________ Year: _______ VIN: ___________________________ Purchase Date: _________________Price: _________________ Sale Date: _____________________Price: _________________ Purchaser: __________________________ Address of Purchaser: _____________________________________________________________________ Owner if not you: _________________________________________________________________________ Make: ________________ Model: _____________ Year: _______ VIN: ____________________________ Purchase Date: _________________Price: _________________ Sale Date: _____________________Price: _________________ Purchaser: ___________________________ Address of Purchaser: ______________________________________________________________________ Owner if not you: __________________________________________________________________________ 8. If you own or owned during the last four years, or use any firearms, list the make, model, serial number, date of purchase, purchase price. If you no longer own the firearm, identify date of sale, sale price, and name and address of purchaser. Provide additional information on a separate sheet of paper, if necessary. Make: ________________ Model: _____________ Serial Number: ________________________________ FORM 7 JDF 105CS R1-18 PATTERN INTERROGATORIES UNDER C.R.C.P. 369(g) - INDIVIDUAL Page 2 of 5 Purchase Date: _________________Price: _________________ Sale Date: _____________________Price: _________________ Purchaser: ___________________________ Address of Purchaser: ______________________________________________________________________ Owner if not you: __________________________________________________________________________ Make: ________________ Model: _____________ Serial Number: _______________________________ Purchase Date: _________________Price: _________________ Sale Date: _____________________Price: _________________ Purchaser: __________________________ Address of Purchaser: _____________________________________________________________________ Owner if not you: __________________________________________________________________________ 9. If you own or owned during the last four years, or regularly use any personal property NOT DESCRIBED ABOVE for which the purchase prices was $500.00 or more, describe each item by make, model, date of purchase, purchase price, name of owner if only used by you. If you no longer own the item, identify date of sale, sale price, and name and address of purchaser. Provide additional information on a separate sheet of paper, if necessary. Make: ________________ Model: _____________ Purchase Date: ________________ Price: __________ Sale Date: _____________________Price: _________________ Purchaser: ___________________________ Address of Purchaser: _____________________________________________________________________ Owner if not you: ___________________________________________________ Make: ________________ Model: _____________ Purchase Date: ________________ Price: __________ Sale Date: _____________________Price: _________________ Purchaser: ___________________________ Address of Purchaser: ______________________________________________________________________ Owner if not you: ___________________________________________________ Make: ________________ Model: _____________ Purchase Date: ________________ Price: __________ Sale Date: _____________________Price: _________________ Purchaser: ___________________________ Address of Purchaser: ______________________________________________________________________ Owner if not you: __________________________________________________________________________ 10. State the name, address, and telephone number of your spouse, if you are married and if not, a close relative not living with you, indicating their relationship to you. Name: ____________________________________________ Relationship: _______________________ Address: ________________________________________________________________________________ Phone Number: _____________________________ 11. Produce and attach to your answers, copies of the following documents for the last four years: a. Your federal and state tax returns with all attachments. b. The deed to or the lease for your home. c. Your driver’s license. d. Your last pay stub from your employer(s). e. Your last bank statement(s). 12. If you wish to propose an arrangement to pay the judgment, state the proposed terms: _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ FORM 7 JDF 105CS R1-18 PATTERN INTERROGATORIES UNDER C.R.C.P. 369(g) - INDIVIDUAL Page 3 of 5 If your are self-employed, you must also answer the following questions. 13. What is the full name, address, and phone number of the business? Name: _______________________________________________ Phone Number: ___________________ Address: _______________________________________________________________________________ 14. What does your business do? _____________________________________________________________ 15. On a separate sheet of paper, list the name, address and phone number of each business customer during the past three months, including the amount and reason for any money owed, if any. 16. State the name, address, account number and type of account for every financial institution (bank, savings and loan, credit union, brokerage house) where the business has an account. Provide additional information on a separate sheet of paper, if necessary. Name: __________________________________________________________________________________ Address: ________________________________________________________________________________ Type of Account: _____________________________ Account Number (last 4-digits): ________________ Name: ___________________________________________________________________________________ Address: _________________________________________________________________________________ Type of Account: _____________________________ Account Number (last 4-digits): _________________ 17. If the business owns or owned during the last four years, or regularly uses, any personal property for which it paid $500.00 or more, describe each item by make, model, date of purchase, purchase price, name of owner if only used by you. If the business no longer owns the item, identify date of sale, sale price, and name and address of purchaser. Provide additional information on a separate sheet of paper, if necessary. Make: ________________ Model: _____________ Purchase Date: ________________ Price: __________ Sale Date: _____________________Price: _________________ Purchaser: ___________________________ Address of Purchaser: ______________________________________________________________________ Owner if not you: __________________________________________________________________________ Make: ________________ Model: _____________ Purchase Date: ________________ Price: __________ Sale Date: _____________________Price: _________________ Purchaser: ___________________________ Address of Purchaser: ______________________________________________________________________ Owner if not you: __________________________________________________________________________ Make: ________________ Model: _____________ Purchase Date: ________________ Price: __________ Sale Date: _____________________Price: _________________ Purchaser: ___________________________ Address of Purchaser: ______________________________________________________________________ Owner if not you: __________________________________________________________________________ 18. Produce and attach to your answers, copies of the following documents for the business: a. All bank records for the past three months. b. All payroll records for the past three months. c. Current list of the accounts receivable. d. Profit and Loss Statements for the current and prior year. FORM 7 JDF 105CS R1-18 PATTERN INTERROGATORIES UNDER C.R.C.P. 369(g) - INDIVIDUAL Page 4 of 5 e. Current asset list, including the inventory. Failure to respond fully, accurately and timely to these interrogatories could result in a citation for contempt of court. I do hereby affirm under penalty of perjury that I have read each of the above questions and answered them fully and truthfully.  By checking this box, I am acknowledging I am filling in the blanks and not changing anything else on the form.  By checking this box, I am acknowledging that I have made a change to the original content of this form. Dated: ________________________________ ___________________________________________ Judgment Debtor Subscribed and affirmed, or sworn to before me in the County of ______________________, State of ________________, this ___________ day of _______________, 20______. My Commission Expires: ________________________ ___________________________________________ Notary Public /Deputy Clerk CERTIFICATE OF SERVICE BY MAILING (To be performed by Clerk within three days of filing) I hereby certify that on ______________________(date), I mailed a true and complete copy of the PATTERN INTERROGATORIES UNDER C.R.C.P. 369(g) - INDIVIDUAL by placing them in the United States Mail, postage pre-paid to the Defendant at the address listed below. To: _ ________ _ _ ______________________________________________ Clerk of Court/Deputy Clerk  (If applicable) Plaintiff notified of non-service on ____________________________ (date). Clerk’s Initials _ ___________ FORM 7 JDF 105CS R1-18 PATTERN INTERROGATORIES UNDER C.R.C.P. 369(g) - INDIVIDUAL Page 5 of 5