Bankruptcy Information Questionnaire

Bankruptcy Information Questionnaire

This Bankruptcy Information Questionnaire (the "Questionnaire") is completed by Debtor Name: and Attorney/Firm Name: . The information provided herein will be relied upon by Attorney for preparation and filing of any petition, schedules, statements, and related pleadings. Completion Date:

RECITALS

WHEREAS, Debtor seeks to provide Attorney with a complete and accurate statement of the Debtor's assets, liabilities, income, and expenditures to enable Attorney to assess and, if appropriate, file a petition under the Bankruptcy Code; and

WHEREAS, Attorney requires the information requested in this Questionnaire to determine the appropriate chapter, exemptions, schedules, and statements, and to prepare required creditor and court notices; and

WHEREAS, Debtor acknowledges that the accuracy of the information provided is material to the legal services to be rendered and that omissions or inaccuracies may result in adverse legal consequences, including sanctions or denial of relief.

NOW THEREFORE, in consideration of the mutual covenants and for the purposes stated herein, Debtor submits the following information under penalty of perjury.

1. DEBTOR IDENTIFICATION

2. BANKRUPTCY CASE INFORMATION

Proposed Chapter(s): Chapter 7 Chapter 11 Chapter 13

Yes No

3. ASSETS

List real property owned or partially owned (address and estimated fair market value):

List bank accounts, investments, and account balances:

4. LIABILITIES

Provide the names of primary unsecured creditors and approximate balances (list up to five principal creditors):

5. INCOME, EMPLOYMENT, AND EXPENSES

6. TRANSFERS, LITIGATION, AND CLAIMS

Have you made any transfers of property, payments to insiders, or gifts within the past two years that you believe may be subject to challenge by a trustee?

Yes No

Are there any pending lawsuits, administrative proceedings, or claims against Debtor?

Yes No

7. TAXES

Have you filed federal or state tax returns for the past four years?

Yes No

8. ADDITIONAL INFORMATION AND DOCUMENTS

Please indicate documents provided to Attorney: Paystubs Bank statements Tax returns Deeds/Vehicle titles

9. REPRESENTATIONS, CERTIFICATIONS, AND AUTHORIZATIONS

Debtor represents and certifies that all information provided in this Questionnaire is true, correct, and complete to the best of Debtor's knowledge. Debtor understands that intentional falsification or omission of material information may constitute perjury or fraud and may expose Debtor to civil or criminal liability.

Debtor authorizes Attorney to obtain and review credit reports, account records, and other information reasonably necessary to prepare the bankruptcy petition and to communicate with creditors, courts, and third parties on Debtor's behalf in furtherance of representation.

Debtor acknowledges that Attorney has not guaranteed any particular result and that the Court will determine eligibility for relief and the outcome of claims.

10. NOTICES

All notices required or permitted under this Questionnaire shall be given in writing to the addresses provided below. Notice to Attorney is effective upon actual receipt by Attorney; notice to Debtor is effective upon delivery to the residence address set forth in Section 1.

11. MISCELLANEOUS PROVISIONS

Governing Law: This Questionnaire shall be governed by and construed in accordance with the laws of the state in which Debtor resides, without regard to conflict of law principles. The parties consent to the jurisdiction and venue of the bankruptcy court and state courts as applicable.

Entire Agreement: This Questionnaire, together with any engagement letter or retention agreement executed between Debtor and Attorney, constitutes the entire understanding between the parties with respect to the matters addressed herein and supersedes all prior oral and written statements.

Severability: If any provision of this Questionnaire is held to be invalid or unenforceable, the remaining provisions shall remain in full force and effect to the fullest extent permitted by law.

Amendments and Waiver: Any amendment to this Questionnaire must be in writing signed by both Debtor and Attorney. No waiver of any provision shall be effective unless in writing and signed by the party waiving compliance.

CERTIFICATION

I declare under penalty of perjury under the laws of the United States and the applicable state that the foregoing statements and answers are true and correct to the best of my knowledge, information, and belief.

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