Thank you for asking us to assist you in reviewing your options, including possible bankruptcy. The following questions will assist us in giving you advice such as whether bankruptcy is appropriate, the best time for filing and what danger points you need to be aware of. Please understand that just because you fill out this information you have not committed to filing a bankruptcy. Nor, have we committed to representing you in a bankruptcy. Once we receive your form we will all public records which will help us to guide you through the very complicated bankruptcy process.
In general, assets that were acquired before the time when the bankruptcy petition is filed-so-called pre-petition assets-are available to satisfy pre-petition debts. Over-generalizing, one can say that post-petition assets belong to the debtor and are not encumbered by any liabilities that were discharged in bankruptcy. By the same token, any liabilities incurred by the debtor post-petition may not be discharged in the bankruptcy proceeding, nor should the bankruptcy process compel the pre-petition creditors to bear any burden as a result of these post-petition obligations.
Once you have completed the video (step one) and questionnaire (step two) please send it to JAY@DIANEDRAIN.COM or fax it to 602-249-1969. If you fax the form please use black pen or type (blue ink or pencil are rarely legible on a fax copy). We know that you are anxious to talk to Ms. Drain, therefore we ask that you be thorough in finishing this form. Jay will review it, if it is complete he will give it to Ms. Drain who will call to schedule your 30 minutes free telephonic appointment. Do not send this form to Ms. Drain - she receives between 200-400 spams per day and your form may end up in her spam box. Again, please send it to Jay at Jay@DianeDrain.com.
During the free telephonic discussion Ms. Drain will review each page of this questionnaire, ask you questions and answer your questions. Consider writing your questions down beforehand so that you are prepared for the phone conference. At the end of this free telephonic discussion Ms. Drain will be able to quote a fee for her services. But that quote is limited to the circumstances you disclose and only for 3 months following the telephonic discussion. No further services will be rendered by our office, unless you request them and sign a retainer agreement.
For some it is necessary that I remind you about following directions. For most of you this is not necessary - to you I apologize for the following: 1) Please do not send this form until you have completed step one (watched the educational videos). 2) It is very important that every question on this form be answered and that you sign the three documents attached. If the form is not 100% complete (including the signatures) then Jay will contact you. He will then file your form away until he receives a completed form. 3) Do not forget to complete the means test accurately.
This firm is in the business of helping people and companies file for bankruptcy protection. Therefore, Congress has decided that we must call ourselves "debt relief agents". We look forward to hearing from you.
GENERAL INFORMATION
__ Yes ___No Have you (or your spouse) ever filed bankruptcy before? If yes, list year, state and case number. ______________________ This includes any case which may have been filed, but not completed, but no discharge entered. __ Yes ___No Have you (or your spouse) ever used a false social security number or someone else's name to acquire debt? If so, it is very important that we talk about your situation. This is very serious and could be grounds for criminal action and/or deportation. __ Yes ___No Do you (or your spouse) own any property that was part of a bankruptcy in the last 2 years? If so, explain:____________________________________________________________
__ Yes ___No
Are both you and your spouse
filing this bankruptcy together?
Have either you (or your spouse) used any other name during the past 6 years? (Example: maiden name, last name from previous marriage, legal name change, etc.) ٱ__ Yes ___No If yes, write the NAME and DATE(S) USED below:
Name Used__________________________________ Dates Used thru_____________________
Name Used__________________________________ Dates Used thru_____________________
How did you find out about our services? __________________________________
PLEASE ANSWER THE FOLLOWING QUESTIONS:
__ Yes ___No I certify that I watched the educational videos about the bankruptcy process. (If you have not, then please do so before sending this form to our office.)
__ Yes ___No Is there a
foreclosure or trustee's sale pending?
If so: (1) what is the total
of your personal debts (both
secured and unsecured): $___________
VERY IMPORTANT: What do
you expect bankruptcy to do for you:
_________________________________________________________________________ The following are general questions to determine your current situation. If you are married then please fill out these forms with the husband as the "client" and the wife as the "co-client". This is not meant to be deferential, but is done so that we can keep each person's situation clearly defined. Thank you. __ Yes __ No Is there an emergency requiring immediate filing?
If so, why?
________________________ If not, explain __________________________________________________________________ __ Yes __ No Do you (or your spouse) owe any back child support or alimony?
If so, explain
__________________________________________________________________
If so, what and how much:
_____________________________________________ __ Yes __No Is a landlord trying to evict you from your property?
If so, did you landlord obtain
a Forcible Entry & Detainer Order? When?
__________________ __ Yes __ No Other problems? Explain _________________________________________________ __ Yes __ No If married, did just one spouse incur the debts before the marriage?
If so, explain
__________________________________________________________________ There are certain issues that determine whether or not it is appropriate to file now. Check if any apply to your circumstances.
__ Yes __ No Have you taken the required credit counseling briefing in the last 6 months? __ Yes __ No Do you (or your spouse) have a probable inheritance in the next 6 months? If so, explain ________________________________________________________ __ Yes __ No Did you (or your spouse) refuse any inheritance in the last 6 years?
If so, explain
________________________________________________________
If so, explain
________________________________________________________
If so, approximately how
much. ______________________________________________ If so, when and how much. ______________________________________________ __ Yes __ No Even if you never expect to collect, does anyone owe you money for any reason whatsoever? If so, when and how much. ______________________________________________ __ Yes __ No Do you (or your spouse) have a personal injury claim pending or payable? If so, when and how much. ______________________________________________ __ Yes __ No Do you (or your spouse) have a right to sue anyone for anything?
If so, explain
__________________________________________________________ If so, describe ________________________________________________________ __ Yes __ No Have you sold or transferred any property (land, cars, businesses, any items of value) to anyone who was not a friend or relative in the last 2 years?
If so, describe
________________________________________________________ If so, describe ________________________________________________________ __ Yes __ No Have you (or your spouse) paid any money or transferred any assets to a friend or relative in the last year? If so, describe ________________________________________________________
When was the month and year that you last used your
credit cards?
__________________________ __ Yes __ No Do you have any student loans?
If so, please understand that
most student loans must be paid back, despite your
bankruptcy. If so, explain:________________________________________________________ __ Yes __
No Do you (or your spouse) understand that
any debts from obtaining money, property, or services by
fraud may survive the bankruptcy? __ Yes __ No Do you (or your spouse) owe any fines or penalties? (e.g.: court fines, or tickets) If so, describe _________________________________________________________ __ Yes __ No Do you (or your spouse) have any stocks, bonds (including savings bonds) or mutual funds? If so, describe ________________________________________________________ __ Yes __
No Do you (or your spouse) have
any retirement accounts?
__ Yes __ No If so, have you contributed
any money into the account(s) in the last 120 days?
If so, were those funds deposited more than 1 year ago? ___
2 years ago___? (541(b)(5) &(6))
HOME, LAND AND VEHICLES
First lender: ________________________ Debt owed $ __________ Arrears* $_________ Second lender: ________________________ Debt owed $ __________ Arrears* $_________
Third lender:
________________________ Debt owed $ __________
Arrears* $_________ __ Yes __ No Is there a pending foreclosure or trustee’s sale? If so, what is the date and time of foreclosure: _________________________________________ If there is a sale, then provide copies of trustee sale documents and make sure that the trustee's name is listed below as a creditor. It is your responsibility to confirm this date and to keep track of the date at all times; including the entire pendency of your bankruptcy. This office will not monitor the date of sale for you, but we be happy to answer your questions. __ Yes __ No Is your home loan a VA loan (personal liability for VA loan)? __ Yes __
No Are you modifying any of your home
loans? __ Yes __
No Do you have a homeowner's
association?
If not, when was a last payment
made?________________ Arrears $_________ __ Yes __
No In the last 10 years have any mortgage
payments been made in addition to the regular monthly
payment? If so, describe
____________________________________ First lender: ________________________ Debt owed $ __________ Arrears* $_________ Second lender: ________________________ Debt owed $ __________ Arrears* $_________ Third lender: ________________________ Debt owed $ __________ Arrears* $_________ *arrears means the amount you are behind on your payments. __ Yes __ No Do you have a homeowner's association on this second property? __ Yes __ No Are the homeowner's association payments current? If not, when was a last payment made?________________ Arrears $_________
__ Yes __ No Do you (or your spouse) own other real estate, (e.g. other house/land, time shares, etc)? Describe: ______________________ Fair market value $_________, Debt owed $ ______ Describe: ______________________ Fair market value $_________, Debt owed $ ______ Describe: ______________________ Fair market value $_________, Debt owed $ ______
__ Yes __ No Do you (or your spouse) own any vehicles? List all cars in your name, including those that you are making payments on. Fair market value: www.kbb.com (private party value). I cannot give you good advice without the fair market value.
Describe: __________________
Fair market value $______, Debt owed $ ________
Describe: __________________
Fair market value $______, Debt owed $ ________
Describe: __________________
Fair market value $______, Debt owed $ ________
Describe: __________________
Fair market value $______, Debt owed $ ________ (no redemption in 13 if purchased in last 2 1/2 years) __ Yes __ No Did you refinance any of these vehicles after they were originally purchased? __ Yes __ No Did you (or your spouse) finance these vehicles with a credit union?
__ Yes __ No Do you (or your spouse) own any luxury items that total more than $50,000 (businesses, stock, investments, land, etc)? If so, explain __________________________________________________________________ __ Yes __ No Do you (or your spouse) own any valuable items that you are concerned about losing? If so describe, include their value: __________________________________________________ __ Yes __
No Did you (or your spouse) use any
household furnishings, jewelry or vehicles as collateral for
a loan? __ Yes __ No Do you (or your spouse) own any items that are not on the attached exemption list?
If so, list item, including
fair market value:
____________________________________________
If so, explain
___________________________________________________________________ __ Yes __ No Do you (or your spouse) have any sole and separate assets? Make sure to include the resale value. (Sole and separate assets are those brought into the marriage, given to you (or your spouse) during marriage by someone who is not your spouse, inherited, or purchased from income of your sole and separate property and THAT WERE NEVER COMINGLED.) If so, list item, including fair market value: ____________________________________________
BUSINESSES __ Yes __ No Do you (or your spouse) own or have any interest in any businesses?
If what would a third party
pay for your interest in the business:
$_____________________ __ Yes __ No Does your business have any leases on anything (cars, equipment, land)? If so, explain ________________________________________________________________ __ Yes __ No Do you (and your spouse) understand that by filing for bankruptcy you may surrender your ability to control your business? This result may differ if you are filing a chapter 13 and not a chapter 7.
Questions:
________________________________________________________________
INCOME AND TAXES Total
amount of your gross income (before taxes/insurance)
over the last 6 months? $___________ __ Yes __ No Do you have a regular income? If so, what is your monthly gross (before taxes)? $________ Net (after taxes and insurance) $_______ __ Yes __ No Does your Spouse have a regular income? If so, what is their monthly gross (before taxes)? $_________ Net (after taxes and insurance) $_______ Monthly
income from retirement, social security, alimony, child
support, rent, gifts? $____________ __ Yes __ No Do you (or your spouse) have any back wages, vacation or sick pay owing?
If so, how much per month (average):
____________________________________________ __ Yes __
No Have you (or your spouse) filed all
required income tax returns, both federal and state? IF NOT
THOSE RETURNS MUST COMPLETED BEFORE YOUR BANKRUPTCY
DOCUMENTS CAN BE COMPLETED. WE DO NOT GIVE TAX ADVICE,
BUT CAN REFER YOU TO A TAX SPECIALIST.
If so, explain what type of
debt, year due, when was return filed,
etc._______________________
If so, explain what type of
debt, year due, when was return
filed.___________________________ MONTHLY BUDGET This form details how much you spend each month on living expenses. Be sure to include the MONTHLY (not yearly) amount for each expenditure. For utilities, your bill may be higher an the summer than in the winter, so include the amount that is an average covering the last 12-month period. If your spouse does not reside in your home then make a second copy of this budget for their expenses.
TOTAL AMOUNT OF MONTHLY EXPENSES: ___________________
NOTES: This is more of what Congress decided to burden you with. Neither you or I like it but it is the law.
Example: John and Mary are filling out this form on the 23rd of the June. They have a renter and their mother has been giving them $200.00 a month for the last 5 months.
If your average gross income exceeds the following you will need to answer the rest of the questions set out below. Average gross income is determined by adding together all income for the last full 6 months and dividing it by 6. Include the income for everyone who lives in your home. If more than 4 people live in your home add $575 per month. Click here for updated figures.
Additional questions - answer only if you income exceeds the amount set forth above. Instructions for the following questions: These questions pertain NOT to what you actually paid or received over the last six months. Instead, these expenses are those that you will expend or should expend in the future (e.g.: what is the correct amount you should be deducting from your paycheck(s), if you want, but do not have life insurance, disability insurance, or health savings plan, etc.)
1)
Average
monthly taxes (federal, state, FICA, social security,
Medicare, self-employment, etc). If you are married
add both figures together as one number $__________
Additional issues: 1) Amount of
back taxes that you owe $__________ Year(s) tax debt
due: _________________ _______________________________________________________________________________________________ REMINDER: Once you have completed Step One and questionnaire please send it to JAY@DIANEDRAIN.COM or fax it to 602-249-1969. If you are faxing the form please use black pen or type (blue ink or pencil are rarely legible on a fax copy). We know that you are anxious to talk to Ms. Drain, therefore we ask that you be thorough in finishing this form. Jay will review it, if it is complete he will give it to Ms. Drain who will call to schedule your telephonic appointment. Do not send this form to Ms. Drain - she receives between 200-400 spams per day and your form may end up in her spam box. Again, please send it to Jay at Jay@DianeDrain.com.. _______________________________________________________________________________________________
IMPORTANT NOTICES:
The following notices are required pursuant to 527(a)(2). By signing below you acknowledge that 1) You understand that all information that you are required to provide to complete any documents filed with the Bankruptcy Court must be complete, accurate and truthful; 2) That you will fully and completely disclose all assets and all liabilities in the documents filed with the Bankruptcy Court. 3) That the value of each secured personal property asset is the replacement value ("the price a retail merchant would charge for property of that kind considering the age and condition of the property at the time the value is determined."). 4) Current Monthly income, the amounts specified in Section 707(b)(2), and, in a case under Chapter 13, disposable income (determined in accordance with Section 707(b)(2)) are required to be stated after reasonable inquiry. 5) That you have fully disclosed all sources of income on any documents filed with this court. 6) That you understand that any information set forth either in the documents filed with the Bankruptcy Court, or testified to under oath may be audited and that failure to provide accurate information may result in the dismissal of your bankruptcy case or other sanctions, including criminal sanctions. 7) Both you agree that a faxed or e-mailed signature shall be sufficient to indicate agreement to these notices.
Dated:______________________________________
Signed:____________________________________ Signed: _________________________________
UNITED STATES BANKRUPTCY COURT NOTICE TO INDIVIDUAL CONSUMER DEBTOR UNDER § 342(b) OF THE BANKRUPTCY CODE In accordance with § 342(b) of the Bankruptcy Code, this notice: (1) Describes briefly the services available from credit counseling services; (2) Describes briefly the purposes, benefits and costs of the four types of bankruptcy proceedings you may commence; and (3) Informs you about bankruptcy crimes and notifies you that the Attorney General may examine all information you supply in connection with a bankruptcy case. You are cautioned that bankruptcy law is complicated and not easily described. Thus, you may wish to seek the advice of an attorney to learn of your rights and responsibilities should you decide to file a petition. Court employees cannot give you legal advice.
Chapter 13: Repayment of All or Part of the Debts of an Individual with Regular Income ($150 filing fee, $39 administrative fee: Total fee $189) 1. Chapter 13 is designed for individuals with regular income who would like to pay all or part of their debts in installments over a period of time. You are only eligible for chapter 13 if your debts do not exceed certain dollar amounts set forth in the Bankruptcy Code.
1. Services Available from Credit Counseling Agencies With limited exceptions, § 109(h) of the Bankruptcy Code requires that all individual debtors who file for bankruptcy relief on or after October 17, 2005, receive a briefing that outlines the available opportunities for credit counseling and provides assistance in performing a budget analysis. The briefing must be given within 180 days before the bankruptcy filing. The briefing may be provided individually or in a group (including briefings conducted by telephone or on the Internet) and must be provided by a nonprofit budget and credit counseling agency approved by the United States trustee or bankruptcy administrator. The clerk of the bankruptcy court has a list that you may consult of the approved budget and credit counseling agencies.
In addition, after filing a bankruptcy case, an individual debtor generally must complete a financial management instructional course before he or she can receive a discharge. The clerk also has a list of approved financial management instructional courses.
2. The Four Chapters of the Bankruptcy Code Available to Individual Consumer Debtors
Chapter 7: Liquidation ($220 filing fee, $39 administrative fee, $15 trustee surcharge: Total fee $274) 1. Chapter 7 is designed for debtors in financial difficulty who do not have the ability to pay their existing debts. Debtors whose debts are primarily consumer debts are subject to a “means test” designed to determine whether the case should be permitted to proceed under chapter 7. If your income is greater than the median income for your state of residence and family size, in some cases, creditors have the right to file a motion requesting that the court dismiss your case under § 707(b) of the Code. It is up to the court to decide whether the case should be dismissed. 2. Under chapter 7, you may claim certain of your property as exempt under governing law. A trustee may have the right to take possession of and sell the remaining property that is not exempt and use the sale proceeds to pay your creditors. 3. The purpose of filing a chapter 7 case is to obtain a discharge of your existing debts. If, however, you are found to have committed certain kinds of improper conduct described in the Bankruptcy Code, the court may deny your discharge and, if it does, the purpose for which you filed the bankruptcy petition will be defeated. 4. Even if you receive a general discharge, some particular debts are not discharged under the law. Therefore, you may still be responsible for most taxes and student loans; debts incurred to pay nondischargeable taxes; domestic support and property settlement obligations; most fines, penalties, forfeitures, and criminal restitution obligations; certain debts which are not properly listed in your bankruptcy papers; and debts for death or personal injury caused by operating a motor vehicle, vessel, or aircraft while intoxicated from alcohol or drugs. Also, if a creditor can prove that a debt arose from fraud, breach of fiduciary duty, or theft, or from a willful and malicious injury, the bankruptcy court may determine that the debt is not discharged.
Chapter 13: Repayment of All or Part of the Debts of an Individual with Regular Income ($150 filing fee, $39 administrative fee: Total fee $189) 1. Chapter 13 is designed for individuals with regular income who would like to pay all or part of their debts in installments over a period of time. You are only eligible for chapter 13 if your debts do not exceed certain dollar amounts set forth in the Bankruptcy Code. 2. Under chapter 13, you must file with the court a plan to repay your creditors all or part of the money that you owe them, using your future earnings. The period allowed by the court to repay your debts may be three years or five years, depending upon your income and other factors. The court must approve your plan before it can take effect. 3. After completing the payments under your plan, your debts are generally discharged except for domestic support obligations; most student loans; certain taxes; most criminal fines and restitution obligations; certain debts which are not properly listed in your bankruptcy papers; certain debts for acts that caused death or personal injury; and certain long term secured obligations.
Chapter 11: Reorganization ($1000 filing fee, $39 administrative fee: Total fee $1039) Chapter 11 is designed for the reorganization of a business but is also available to consumer debtors. Its provisions are quite complicated, and any decision by an individual to file a chapter 11 petition should be reviewed with an attorney.
Chapter 12: Family Farmer or Fisherman ($200 filing fee, $39 administrative fee: Total fee $239) Chapter 12 is designed to permit family farmers and fishermen to repay their debts over a period of time from future earnings and is similar to chapter 13. The eligibility requirements are restrictive, limiting its use to those whose income arises primarily from a family-owned farm or commercial fishing operation.
3. Bankruptcy Crimes and Availability of Bankruptcy Papers to Law Enforcement Officials A person who knowingly and fraudulently conceals assets or makes a false oath or statement under penalty of perjury, either orally or in writing, in connection with a bankruptcy case is subject to a fine, imprisonment, or both. All information supplied by a debtor in connection with a bankruptcy case is subject to examination by the Attorney General acting through the Office of the United States Trustee, the Office of the United States Attorney, and other components and employees of the Department of Justice.
WARNING: Section 521(a)(1) of the Bankruptcy Code requires that you promptly file detailed information regarding your creditors, assets, liabilities, income, expenses and general financial condition. Your bankruptcy case may be dismissed if this information is not filed with the court within the time deadlines set by the Bankruptcy Code, the Bankruptcy Rules, and the local rules of the court.
Certificate of the Debtor(s) I (We), the debtor(s), affirm that I (we) have received and read this notice.
Date: ______________
X______________________________________ X___________________________________ Signature of Debtor Signature of Joint Debtor (if any) _______________________________________________________________________________________________ Notice required by Bankruptcy Code Section 527(c)(1) and 521(b):
Information to the Assisted
Person (Debtor) on Section 521 of the Code sets out the Debtor's duties related to the filing of a bankruptcy case. As you fill out the schedules and statement of affairs, you should keep the following in mind: 1) Completing the income and expense pages accurately and completely is critical
a.
To compile your income, refer to recent pay stubs and last
year's income tax returns. Account for overtime,
investment dividends and other earnings. _______________________________________________________________________________________________ THE FOLLOWING DOCUMENT IS INTENDED TO BE ON A SEPARATE PAGE Notice required by Bankruptcy Code Section 527(b) IMPORTANT INFORMATION ABOUT BANKRUPTCY ASSISTANCE SERVICES FROM AN ATTORNEY
If you decide to seek bankruptcy relief, you can represent yourself, hire a qualified bankruptcy attorney, or you are able to answer all questions related to bankruptcy – hire a bankruptcy petition preparer that is not an attorney. Under Arizona law the Arizona Supreme Court must license all Bankruptcy Petition Preparer and they may not give any legal advice, including explaining most of the terms contained in the bankruptcy forms. The law requires that any Attorney or Bankruptcy Petition Preparer give you a written contract specifying the work to be done and the fees to be charged.
Before filing any bankruptcy case you and your attorney should analyze your eligibility for different forms of relief available under the bankruptcy code and which type of bankruptcy relief is most beneficial for you. Be sure you understand that relief you can obtain and its limitations. To file a bankruptcy case, documents called a Petition, Schedules and Statement of Financial Affairs, as well as in some cases a Statement of Intention, must be prepared correctly and filed with the bankruptcy Court. You will have to pay a filing fee to the court. Within a few weeks after your case is filed with the Court you will be required to attend a meeting of creditors where the Trustee assigned to your case will swear you to tell the truth and ask you a few questions. Creditors, should they be present, can also ask questions. In most cases no creditors are ever present.
If you choose a chapter 7 case, you may be asked by a creditor who has a lien on your car, computer, appliances or furniture to reaffirm a debt. You should first obtain legal counsel before making any decision related to reaffirming any debt. A creditor is not permitted to coerce or bully you into signing a reaffirmation agreement.
If you choose to file a chapter 13 case so that you can pay arrears on your home, back taxes, child support or your car, then you will also need legal assistance in planning for a successful chapter 13 case and the confirmation process which is part of every chapter 13 case. It is very rare for anyone without an attorney to successfully complete a chapter 13.
In rare cases there is litigation in a chapter 7 case. You can represent yourself - but it is a complicated process and one that you will rarely be successful in without legal counsel.
Anytime you hire a bankruptcy professional you must be provided with a contract describing the services and fees to be charged. Click here for our basic chapter 7 and chapter 13 retainer contract. The fees set forth in this sample retainer agreement are subject to change without notice. Each client will be given a retainer agreement which details the relationship of the client and the attorney. By signing below you are certifying that you read the our basic chapter 7 and chapter 13 retainer contract explaining the proposed services that may be provided, plus the fees and terms.
Keep a copy of this entire document for your records..
Even though you have signed these documents, at no time are you agreeing to file a bankruptcy. Congress has decided that you must receive all these warnings. Again, I apologize for this burden.
Dated:____________________________________
Signed:____________________________________ Signed: __________________________________
THIS DOCUMENT IS INTENDED ONLY FOR USE OF POTENTIAL CLIENTS OF OUR FIRM. |
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