Fill and Sign the Creditor Debt 497331643 Form

Debtor's Affidavit of Financial Status to Induce Creditor to Compromise or Write off the Debt which is Past Due STATE OF ____________________ COUNTY OF _______________________ PERSONALLY appeared before me, the undersigned authority in and for said county and state, _________________ (Name of Affiant) , who, having been being first duty sworn by the undersigned Notary Public, deposes and says: 1. Affiant, hereinafter referred to as Debtor , resides at _______________________ ____________________________________________________ (street address, city, state, zip code) . 2. Debtor has no property or assets of any kind or nature; no money due Debtor from any person; no real property; no stocks, bonds, or funds in any bank; no credits due Debtor ; no beneficial interest in any property held by any other person for Debtor ; and no property standing in the name of assignees, trustees, or any other persons whatever, for Debtor and/or for the benefit of Debtor, with the following exceptions only: A. Personal property described as follows: (description of personal property) _______________________________________________________ __________________________________, all of which would be exempt from attachment of execution under (cite applicable state or federal statute) _____________________. B. A personal residence located at the address set forth in Paragraph 1 above which has an approximate market value of $__________ and on which ________________________ (Name of Bank or Lender) has a first lien, with approximately $___________ left to pay to satisfy said lien. C. (Other exceptions) ___________________________________________ ________________________________________________________________ ________________________________________________________________ 3. Debtor received an Order discharging debts on _______________ (date) , a copy of which is attached hereto as Exhibit A . 4. The Corporation ______________________ (Name of Corporation) in which Debtor and ____________________ (Name of Spouse) , my ____________ ( husband or wife ) were the sole shareholders and _____________________________________ (titles of offices held in Corporation) was dissolved on __________________ (date) . ___________________________________ (Printed Name of Affiant) ___________________________________ (Signature of Affiant) SWORN to and subscribed before me, this the ____ day of ______________, 20_____. _____________________________ NOTARY PUBLIC My Commission Expires: ___________________