Law offices of Chirnese L. Liverpool

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

Please complete this form as accurately as possible. Your form data will be saved on a secure server. You can partially complete this form and return later to finish or edit it at any time.

BANKRUPTCY QUESTIONNAIRE

SECTION 1: INFORMATION ABOUT YOU

How did you hear about us? *

First, Middle, Last Name *

Other names used by you within 8 years, if any:

Social security number (xxx-xx-xxxx) *

Date of birth *

Home address: *

City, State, Zip *

County of residence

Mailing address (If different from home address):

Telephone *

Email address

Have you previously filed bankruptcy? *

Yes

No

If Yes, in what city and state?

SECTION 2: INFORMATION ABOUT YOUR SPOUSE

First, Middle, Last Name

Other names used by your spouse, within 8 years, if any:

Social Security Number

Date of birth

Home address:

Mailing address (if different from home address)

Telephone

Has your spouse previously filed for bankruptcy: If yes, city/state?

SECTION 3: Questions about your household

Who lives with you?

	Name	Relationship	Age
Dependent # 1	Name	Relationship	Age
Dependent # 2	Name	Relationship	Age
Dependent # 3	Name	Relationship	Age
Dependent # 4	Name	Relationship	Age

SECTION 4

1. What is your marital status? *

Do you want to file bankruptcy by yourself or jointly with a spouse? *

Myself

Jointly with spouse

	Name of Lender/ Loan Number	Balance ($)	Value ($)	Monthly payment ($)	Property address	Date opened
Mortgage # 1	Name of Lender/ Loan Number	Balance ($)	Value ($)	Monthly payment ($)	Property address	Date opened
Mortgage # 2	Name of Lender/ Loan Number	Balance ($)	Value ($)	Monthly payment ($)	Property address	Date opened

For the home - do you wish to:

Keep
Surrender

Are you current with all payments?

If you owe money on any motor vehicles, please provide the following information:

	Year, Make & Model	Name of Lender	Balance ($)	Date opened	Monthly payment ($)
Vehicle # 1	Year, Make & Model	Name of Lender	Balance ($)	Date opened	Monthly payment ($)
Vehicle # 2	Year, Make & Model	Name of Lender	Balance ($)	Date opened	Monthly payment ($)

For vehicle #1 do you plan to:

Keep the vehicle - reaffirm the loan and keep making payments to the creditor

Surrender the vehicle to the creditor and discharge all further liability on the loan

Redeem the vehicle - make a lump sum payment to the creditor for its fair market value

I no longer have the vehicle

For vehicle #2 do you plan to:

Keep the vehicle - reaffirm the loan and keep making payments to the creditor

Surrender the vehicle to the creditor and discharge all further liability on the loan

Redeem the vehicle - make a lump sum payment to the creditor for its fair market value

I no longer have the vehicle

Do you owe any student loans? (keep in mind that they are not dischargeable)

yes

no

If you owe any taxes, state the name of the agency to whom the taxes are owed and specify the amount owed for each tax year:

If you owe any delinquent alimony or child support, state the name and mailing address of the person or agency that you owe and the amount owed: (keep in mind these are not dischargeable)

Are you a party to any lease (vehicle, apartment, house, equipment, etc.) that has not yet expired? if so, provide the name and mailing address of the lessor and state whether you want to assume the lease (keep it in effect) or cancel it:

Is anyone other than you (or your spouse, if filing jointly) is responsible on any of your debts as a co-signer or co-debtor, list their name and mailing address and state the name of the creditor to whom the debt is owed.

If anyone has sued you within the past 2 years, provide the following information:

	Name of person or company that sued you	Case number	Court and location where lawsuit was filed	Status of lawsuit
Lawsuit # 1	Name of person or company that sued you	Case number	Court and location where lawsuit was filed	Status of lawsuit
Lawsuit # 2	Name of person or company that sued you	Case number	Court and location where lawsuit was filed	Status of lawsuit
Lawsuit # 3	Name of person or company that sued you	Case number	Court and location where lawsuit was filed	Status of lawsuit
Lawsuit # 4	Name of person or company that sued you	Case number	Court and location where lawsuit was filed	Status of lawsuit

Have you made any gifts or donations within the past 12 months totaling more than $200.00 to any particular person or organization? If so, provide, name, address, date of gift and amount of gift.

Has any of your property (including wages, vehicles, real estate, etc.) been garnished, repossessed or sold at a foreclosure sale within the past 12 months? If so, state the NAME and MAILING ADDRESS of the creditor and the approximate month and year that garnishment, repossession or foreclosure sale occurred:

Have you sold or transferred any property within the past 24 months, if so:

	Name & Address of Transferee	Description of property transferred	Value of property ($)
Transfer # 1	Name & Address of Transferee	Description of property transferred	Value of property ($)
Transfer # 2	Name & Address of Transferee	Description of property transferred	Value of property ($)
Transfer # 3	Name & Address of Transferee	Description of property transferred	Value of property ($)

Have you closed any banks or financial accounts within the past 12 months? If so:

	Location of closed account	Account number	Final balance ($) upon closing	Date closed
Account #1	Location of closed account	Account number	Final balance ($) upon closing	Date closed
Account #2	Location of closed account	Account number	Final balance ($) upon closing	Date closed
Account #3	Location of closed account	Account number	Final balance ($) upon closing	Date closed

Do you have any safe deposit boxes? If so,

	address of safe deposit box	value ($)	Contents
safe deposit box information	address of safe deposit box	value ($)	Contents

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	dates of occupation
Previous address # 2	dates of occupation

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 property	Value
Cash on hand	Description of property	Value
Bank accounts (Type & Bank name)	Description of property	Value
Rent & utility deposits	Description of property	Value
Household furnishings	Description of property	Value
Books, pictures, art objects, collectables	Description of property	Value
Wearing apparel	Description of property	Value
Furs & Jewelry	Description of property	Value
Firearms and photo or hobby equipment	Description of property	Value
Life insurance policies (Term or whole?)	Description of property	Value
Retirement accounts	Description of property	Value
Stocks/bonds	Description of property	Value
Motor vehicles/boats	Description of property	Value
Office equipment/furnishings	Description of property	Value
Other	Description of property	Value

SECTION 6 - Monthly Expenses *

	monthly amount
Rent or Mortgage (ONLY IF YOU ARE CURRENTLY PAYING)	monthly amount
Electricity & Natural gas	monthly amount
Water & Sewer	monthly amount
Telephone (including cell phone)	monthly amount
Trash service (if not included in water bill)	monthly amount
Home maintenance/repairs	monthly amount
Food	monthly amount
Clothing	monthly amount
Laundry & Dry cleaning	monthly amount
Medical & Dental expenses (not covered by insurance)	monthly amount
Transportation (not including car payment or insurance)	monthly amount
Recreation/entertainment	monthly amount
Charitable contributions	monthly amount
Homeowners insurance	monthly amount
Life insurance	monthly amount
Health insurance (not including paycheck deductions)	monthly amount
Automobile insurance	monthly amount
Automobile payments	monthly amount
Alimony or child support you pay	monthly amount
Day care	monthly amount
Regular expenses from operation of business	monthly amount
Other:	monthly amount

Section 7 - Annual Gross Income

Employment Information:

	Debtor	Spouse
Name/Address of Employer	Debtor	Spouse
Length of Employment	Debtor	Spouse
Occupation	Debtor	Spouse
Monthly GROSS income	Debtor	Spouse
Monthly NET income	Debtor	Spouse

Please list your annual gross income for the specified years. For "2017 year to date" list the gross income that you have received so far this year from January 1, 2017 to present. Spouses must list annual incomes separately even if income tax returns are filed jointly. *

	Debtor ($)	Spouse ($)
2018 Year to Date	Debtor ($)	Spouse ($)
2017	Debtor ($)	Spouse ($)
2016	Debtor ($)	Spouse ($)

Non-Employment, Non-Business Income (for ex. unemployment, workers compensation, disability, financial assistance from friends & family, etc.)

	Debtor ($)	Spouse ($)
2018 Year to Date	Debtor ($)	Spouse ($)
2017	Debtor ($)	Spouse ($)
2016	Debtor ($)	Spouse ($)

ADDITIONAL INFORMATION YOU WOULD LIKE TO PROVIDE

Comment:

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. *

Yes

No