Fill and Sign the Financial Information Sheet Virginia

PERSONAL FINANCIAL INFORMATION 1) Name:       Date       First Middle Last Other names used:       First Middle Last Citizenship status:       Address:       Social Security Number:       2) How long have you lived at your current address?       List any other addresses for the past 5 years: Address:       Address:       3) Marital Status: Married Divorced Separated Single Widowed/Widower If married, please list the name of your spouse:       Is your spouse filing bankruptcy? Yes No If yes, please list your spouse’s address and Social Security Number Address:       Social Security Number:       4) List the names and ages of your dependants, if any: Name:       Age:       Relationship:       Name:       Age:       Relationship:       Page 1 of 10 Name:       Age:       Relationship:       5) List your monthly income. Identify the source (employment, spousal support, SSA, etc.), the gross monthly amount, and the net (take-home) amount. Name of Employer/Your Monthly Income Gross Net       $       $             $       $             $       $       Totals $       $       NOTE: Monthly income is not limited to income from employment, but includes social security and supplemental security income, Temporary Assistance for Needy Families (TANF), disability, child support, annuities, food stamps, retirement benefits, etc. 6) Do you have health insurance for: Yourself: Yes No If yes, who is the provider?       Spouse : Yes No If yes, who is the provider?       Children/Dependants: Yes No If yes, who is the provider?       7) Have you ever filed bankruptcy before? Yes No If yes, please list the following: Location where filed:       Case number:       Date filed:       Discharge date:       Page 2 of 10 8) Is your spouse in bankruptcy? Yes No 9) Please list all real estate (for example your home) in which you have an interest: Type of property:       Address:       Market value:       Type of property:       Address:       Market value:       Type of property:       Address:       Market value:       Type of property:       Address:       Market value:       10) How much cash do you normally have on hand?       11) Do you have a bank account? Yes No Account number:       Name of bank:       Address:       Account number:       Name of bank:       Address:       12) Security Deposits Page 3 of 10 Landlord:       Public Utilities:       Telephone:       Others:       13) Estimate value, and where appropriate, give the quantity of any of the following property that you own: Color TV $       Home computer $       B & W TV $       Sofa $       VCR $       Tables $       Microwave $       Stereo $       Chairs $       Bookcases $       Lamps $       Beds, bedding $       Dressers $       Dishes $       Silverware $       Appliances $       Tools $       Carpets $       Books $       Pictures $       Antiques $       Refrigerator $       Clothes $       Wedding/engagement rings $             $             $       14) All jewelry: watches, chains, rings, other       15) List any IRA, KEOGH, or other pension or profit-sharing plans in which you have an interest: Type of plan:       Institution name:       Address:       Account number:       Amount in account:       Type of plan:       Institution name:       Page 4 of 10 Address:       Account number:       Amount in account:       Type of plan:       Institution name:       Address:       Account number:       Amount in account:       16) Do you own any stocks, bonds, annuities, etc.? Yes No Please list with whom, and how much: Institution name:       Address:       Account number:       Amount in account:       Institution name:       Address:       Account number:       Amount in account:       17) Are you, or do you anticipate receiving any tax refunds in the next 180 days? Yes No If so, please estimate how much:       18) Do you have any life insurance policies with a cash value? Yes No List the agency and the amount: Page 5 of 10 Insurance agency:       Address:       Account number:       Amount in account:       Insurance agency:       Address:       Account number:       Amount in account:       19) List all motor vehicles that you own Make and model:       Year:       Value:       How much owed:       Co-owner(s):       Make and model:       Year:       Value:       How much owed:       Co-owner(s):       20) Does anyone owe you any money? Yes No (Include support payments) If so, who, and how much: Name:       Address:       Page 6 of 10 Amount:       Type of debt:                                     21) Please provide an itemized list of your monthly expenses: 1. HOUSING 8. PERSONAL Rent/Mortgage $       Beauty/Barber $       2 nd Mortgage/Home equity $       Other $       Condo/HOA dues $       9. ENTERTAINMENT Property Taxes $       Cable $       Renter’s/Homeowner’s Ins. $       Movie/Video $       Gas/Electric $       Dining Out $       Water/Sewer $       Sports/Hobbies/Clubs/Gym $       Garbage $       Vacations/Travel $       Telephone $       Reading Material/Music $       2. FOOD 10. CLOTHING Groceries $       Purchases $       Household Items $       Laundry/Dry Cleaning $       Lunches (Work/School) $       11. HOME CARE 3. MEDICAL Maintenance/Repairs $       Health Ins. $       Cleaning $       Prescriptions $       Pool Service/Lawn Service $       4. TRANSPORTATION Security System $       Car Payment #1 $       12. MISCELLANEOUS Car Payment #2 $       Pet Care $       Gasoline/Fuel $       Pager/Cell Phone $       Repairs/Maintenance $       Banking Fees $       Insurance $       Postage $       DMV Registration $       Cigarettes $       Tolls/Parking $       Alcohol $       Bus/Subway $       Gifts $       Property Taxes $       Internet/Computer Fees $       5. CHILD CARE Charity Donations $       Daycare/Sitting $       Other Alimony/Child Support $       6. EDUCATION Tuition $       Student Loans $       Page 7 of 10 7. MISCELLANEOUS Taxes $       Life Insurance $       Union Dues $       Savings $       Retirement $       Other $       Total Essential $       Total Non-Essential $       22) Please provide a listing of your creditors (Use your Credit Report): CREDITOR ADDRESS ACCOUNT NO. BALANCE DUE WHETHER DELINQUENT                   $                               $                               $                               $                               $                               $                               $                               $                               $                               $                               $                               $             Page 8 of 10                   $                               $                               $                               $                               $                               $                               $                               $             TOTAL BALANCE DUE $       23) Please provide a listing of any judgments obtained against you: Court Case No. Date of Judgment Amount                   $                         $                         $                         $                         $                         $                         $       Page 9 of 10 24) Additional Information:                                                                                                                                                                                                                                                             Page 10 of 10