Law offices of Chirnese L. Liverpool
6277 Van Nuys Blvd. Suite 126
Van Nuys, CA 91401
(818) 714-2200 ph.
(818) 714-2201 fax

www.liverpoollegal.com
                                                                                     

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BANKRUPTCY QUESTIONNAIRE

SECTION 1: INFORMATION ABOUT YOU

Have you previously filed bankruptcy? *

SECTION 2: INFORMATION ABOUT YOUR SPOUSE

SECTION 3: Questions about your household

Who lives with you?
 NameRelationshipAge
Dependent # 1
Dependent # 2
Dependent # 3
Dependent # 4

SECTION 4

1. What is your marital status? *
Do you want to file bankruptcy by yourself or jointly with a spouse? *
 Name of Lender/ Loan NumberBalance ($)Value ($)Monthly payment ($)Property addressDate opened
Mortgage # 1
Mortgage # 2
For the home - do you wish to:
If you owe money on any motor vehicles, please provide the following information:
 Year, Make & ModelName of LenderBalance ($)Date openedMonthly payment ($)
Vehicle # 1
Vehicle # 2
For vehicle #1 do you plan to:
For vehicle #2 do you plan to:
Do you owe any student loans? (keep in mind that they are not dischargeable)
If anyone has sued you within the past 2 years, provide the following information:
 Name of person or company that sued youCase numberCourt and location where lawsuit was filedStatus of lawsuit
Lawsuit # 1
Lawsuit # 2
Lawsuit # 3
Lawsuit # 4
Have you sold or transferred any property within the past 24 months, if so:
 Name & Address of TransfereeDescription of property transferredValue of property ($)
Transfer # 1
Transfer # 2
Transfer # 3
Have you closed any banks or financial accounts within the past 12 months? If so:
 Location of closed accountAccount numberFinal balance ($) upon closingDate closed
Account #1
Account #2
Account #3
Do you have any safe deposit boxes? If so,
 address of safe deposit boxvalue ($)Contents
safe deposit box information
Have you resided at your present home address for less than 3 years? If so, please list the address and dates of occupation
 dates of occupation
previous address # 1
Previous address # 2

SECTION 5: Personal property

Please briefly describe the property you and your spouse own and its estimated GARAGE SALE VALUE (If you had to sell it TODAY at a garage sale -  how much would you receive for it)
 Description of propertyValue
Cash on hand
Bank accounts (Type & Bank name)
Rent & utility deposits
Household furnishings
Books, pictures, art objects, collectables
Wearing apparel
Furs & Jewelry
Firearms and photo or hobby equipment
Life insurance policies (Term or whole?)
Retirement accounts
Stocks/bonds
Motor vehicles/boats
Office equipment/furnishings
Other
SECTION 6 - Monthly Expenses
 monthly amount
Rent or Mortgage (ONLY IF YOU ARE CURRENTLY PAYING)
Electricity & Natural gas
Water & Sewer
Telephone (including cell phone)
Trash service (if not included in water bill)
Home maintenance/repairs
Food
Clothing
Laundry & Dry cleaning
Medical & Dental expenses (not covered by insurance)
Transportation (not including car payment or insurance)
Recreation/entertainment
Charitable contributions
Homeowners insurance
Life insurance
Health insurance (not including paycheck deductions)
Automobile insurance
Automobile payments
Alimony or child support you pay
Day care
Regular expenses from operation of business
Other:

Section 7 - Annual Gross Income

Employment Information:
 DebtorSpouse
Name/Address of Employer
Length of Employment
Occupation
Monthly GROSS income
Monthly NET income
Please list your annual gross income for the specified years.  For "2012 year to date" list the gross income that you have received so far this year from January 1, 2012 to present.  Spouses must list annual incomes separately even if income tax returns are filed jointly.
 Debtor ($)Spouse ($)
2016 Year to Date
2015
2014
Non-Employment, Non-Business Income (for ex. unemployment, workers compensation, disability, financial assistance from friends & family, etc.)
 Debtor ($)Spouse ($)
2016 Year to Date
2015
2014

ADDITIONAL INFORMATION YOU WOULD LIKE TO PROVIDE

I acknowledge that I have disclosed all information and that is truthful.  I also acknowledge that no attorney/client relationship has been established solely by my filling out this questionaire.  I understand that an attorney/client relationship will ONLY be established upon my signing the attorney's retainer agreement and paying the applicable fees. *

Law offices of Chirnese L. Liverpool
6277 Van Nuys Blvd. Suite 126
Van Nuys, CA 91401
ph. (818) 714-2200
fax (818) 714-2201