Virginia Financial Form

PERSONAL FINANCIAL INFORMATION

1) Name: Date

Other names used:

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:

5) List your monthly income. Identify the source, the gross monthly amount, and the net (take-home) amount.

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:

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

Landlord:

Public Utilities:

Telephone:

Others:

13) Estimate value, and where appropriate, give the quantity of any of the following property that you own:

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:

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:

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:

Amount:

21) Please provide an itemized list of your monthly expenses:

22) Please provide a listing of your creditors (Use your Credit Report):

23) Please provide a listing of any judgments obtained against you:

24) Additional Information: