National Divorce & Bankruptcy Center

Bankruptcy Worksheet - Order Form

This worksheet is designed to 'guide' you through the process of gathering the necessary information required to accurately detail your true financial 'picture'

After completing the worksheet, you will be able to evaluate your options and make informed decisions about your financial future.

If you decide that debt releif through federal bankruptcy, and a financial 'fresh start', is the best choice for you ; we will then use the worksheet information to prepare all of your required paperwork, to file and complete, either a chapter 7 or 13 bankruptcy.

Average completion time is 1-2 hours. There may be entire sections that do not apply to your circumstances. Simply leave blank all that do not apply. The information can be quickly copied from your credit report or from billing statements.

ABOUT YOU
Soc.Sec.No.:_______________ e-mail _____________@_______________________
FULL NAME (first/middle/last)_____________________________________________
other names [used in last 6 years (maiden, married, trade names etc.)] _________________________________________________________________
ADDRESS:____________________________________________________________
CITY____________________County___________STATE____ZIP_________________
Mailing address if different_________________________________________________
Phone number:_________________________________

LOCATION OF PRINCIPAL ASSETS (if different from above)
_____________________________________________________________

DEPENDENTS OF DEBTOR(S):
Name_________________________age____Relationship_____________
Name_________________________age____Relationship_____________
Name_________________________age____Relationship_____________
Name_________________________age____Relationship_____________
Name_________________________age____Relationship_____________

NATURE OF DEBT:_____INDIVIDUAL OR _____BUSINESS
(type of business)if applicable_______________________________________

ESTIMATED NUMBER OF CREDITORS:____1-15_____16-49_____50-99
ESTIMATED ASSETS_____under$50,000_____$50-99,000_____$100,000-199,000
ESTIMATED LIABILITIES__under $50,000___$50-99,000___ $100,000-199,000

INDICATE DEBTOR(S) INTEREST IN the PROPERTY (how it is owned):
Circle H for Husband,___W for Wife,___J for joint,___or C for community:

REAL ESTATE PROPERTY - ONLY IF OWNED OR BUYING:
Primary residence of debtor:
Address:________________________________________________
Current Payoff: $____________Current Value: $___________ H__W__J__C___
Mortgage holder __________________________account#____________________
Mortgage holder's address: ______________________________________________
Other real estate owned: Address:_________________________________________
Current Payoff: $__________ Current Value: $_____________H__W__J__C___
Mortgage holder ____________________________account #_________________
Mortgage holder's address: _____________________________________________

Spouse's Occupation______________________Employer:_______________________
Employer's Address:__________________________________How long employed?______

MONTHLY INCOME

Average Monthly Income	_Yours_	*Spouse	*Both__
1. Gross wages, salary, commissions	$	$	$
2. Estimated monthly overtime	$	$	$
3. Subtotal of Income( 1 & 2 above) =	$	$	$
Payroll Deductions	Yours	Spouse	Both
4. Payroll taxes & Social Security	$	$	$
5. Insurance	$	$	$
6. Union dues	$	$	$
7. Other (specify)	$	$	$
9. Subtotal of 4-7 above	$	$	$
10. TOTAL Net Monthly Income (#3 - #9)	$	$	$
Other Income	* Yours*	Spouse	Both
11. Regular income from business, farm or profession	$	$	$
12. Income from real estate property	$	$	$
13. Interest Dividends	$	$	$
14. Alimony or support payments payable to debtor or dependents	$	$	$
15. Social SEcurity or other government benefits	$	$	$
16. Pension and or retirement	$	$	$
17. Other Income (specify)	$	$	$
18. Subtotal of other income (11-17 above)	$	$	$
19. TOTAL MONTHLY INCOME ( 10 + 18 above)	$	$	$

MONTHLY EXPENSES

Monthly Expenses	Debtor	Spouse	__Both__
Rent or mortgage paid monthly	$	$	$
Are real estate taxes included in monthly mortgage payment?	__Yes__No	__Yes__No	*
Is insurance included in monthly mortgage payment?	__Yes__No	__Yes__No	*
Electrictiy	$	$	$
Heating Fuel	$	$	$
Water & Sewer	$	$	$
Telephone	$	$	$
Cable television Service	$	$	$
Other (specify)	$	$	$
Home Repair & upkeep	$	$	$
Food	$	$	$
Clothing	$	$	$
Laundry & dry cleaning	$	$	$
Medical & Dental	$	$	$
Transportation (do not include car payments)	$	$	$
Recreation (newspapers, magazines, entertainment, clubs	$	$	$
Charitable contributions (specify)	$	$	$
Insurance (not deducted from earnings or included in mortgage)	Debtor	Spouse	__Both__
Homeowners or Renters Insurance	$	$	$
Life insurance	$	$	$
Auto Insurance	$	$	$
Other (specify)	$	$	$
Taxes not deducted from wages or included in mortgage (specify)	$	$	$
Monthly Installment Payments (not listed above)	Debtor	Spouse	__Both__
Auto- Make/model________________	$	$	$
Auto - Make/model________________	$	$	$
Creditor:______________________Acct#________________	$	$	$
Creditor:______________________Acct#________________	$	$	$
Creditor:______________________Acct#________________	$	$	$
Creditor:______________________Acct#________________	$	$	$
Creditor:______________________Acct#________________	$	$	$
Creditor:______________________Acct#________________	$	$	$

For purposes of valuing your property for bankruptcy - give garage sale values, not what you originally paid, or what you still owe.
* If you are married or someone else has an ownership interest in your property; Identify your interest in the property (how it is owned) i.e. H = husband, W = wife, J = Joint, C=community property

PROPERTY

Property Type	Description	* Value *	H	W	J	C
Cash on hand	(In your possession)	$	H	W	J	C
Checking, savings, CD's, stocks, etc.	Acct. type________#_____________ Bank/etc:______________________ Address:______________________ Acct. type________#_____________ Bank/etc:______________________ Address:______________________ Acct. type________#_____________ Bank/etc:______________________ Address:______________________	$	H	W	J	C
Security deposits (utility/landlord etc.)	Deposit holder:__________________ Address::_______________________ Deposit holder:__________________ Address:_______________________	$	H	W	J	C
Household Goods & Furnishings	Description	* Value *	H	W	J	C
Living room furnishings	*	$	H	W	J	C
Den/family room	*	$	H	W	J	C
Computer equipment	*	$	H	W	J	C
Stereo & audio	*	$	H	W	J	C
____Television(s)	*	$	H	W	J	C
____VCR(s)	*	$	H	W	J	C
desks, bookcases etc.	*	$	H	W	J	C
1st bedroom	*	$	H	W	J	C
2nd bedroom	*	$	H	W	J	C
3rd bedroom	*	$	H	W	J	C
Kitchen dinette	*	$	H	W	J	C
Dining Room	*	$	H	W	J	C
Refrigerator	*	$	H	W	J	C
Cooking stove	*	$	H	W	J	C
Dishwasher (not builtin)	*	$	H	W	J	C
Microwave	*	$	H	W	J	C
Minor appliances	*	$	H	W	J	C
Washer/dryer	*	$	H	W	J	C
Misc.Other	*	$	H	W	J	C
Personal Property	Description	* Value *	H	W	J	C
books, art, antiques	*	$	H	W	J	C
stamp/coin/record/CD collections	*	$	H	W	J	C
Wearing apparel	*	$	H	W	J	C
Furs, Jewelry	*	$	H	W	J	C
firearms, sports, hobby	*	$	H	W	J	C
surrender value in insurance policies	Name of fund:___________________ Address:_______________________ Policy #________________________	$	H	W	J	C
annuities	*	$	H	W	J	C
IRA, ERISA, KEOGH etc.	Name of fund:__________________ Address:______________________ I.D.#_________________________	$	H	W	J	C
stock, interests in corp./business	*	$	H	W	J	C
interests in partnerships, joint ventures	*	$	H	W	J	C
government & corporate bonds, negotiable/non-negotiable instruments	*	$	H	W	J	C
accounts receivable	*	$	H	W	J	C
alimony, support, property settlement	*	$	H	W	J	C
other liquidated debts owing debtor	*	$	H	W	J	C
equitable or future interests in life estates	*	$	H	W	J	C
interests in estate of decedent	*	$	H	W	J	C
contingent unliquidated claims	*	$	H	W	J	C
patents/copyright, intellectual property	*	$	H	W	J	C
licenses, franchises, general intangibles	*	$	H	W	J	C
Auto(s)	make/model____________________ Lien holder:_____________________ make/model____________________ Lien holder:_____________________	$	H	W	J	C
boats, motors, etc.	*	$	H	W	J	C
Office/Business/Farm	Description	* Value *	H	W	J	C
office equip./furnishings	*	$	H	W	J	C
machinery/fixtures, equipment/supplies	*	$	H	W	J	C
inventory	*	$	H	W	J	C
animals	*	$	H	W	J	C
crops, growing or harvested	*	$	H	W	J	C
farm equip/implements	*	$	H	W	J	C
farm supplies, chemicals & feed	*	$	H	W	J	C
other personal property not listed	*	$	H	W	J	C

SECURED DEBTS (home, auto, any debt with collateral

Creditor Address:	Collateral	Date (mo/yr) incurred	Acct.#	Balance	Value Now
1st Home Bank 123 E. 3rd St. Dallas, Tx 76543	1996 Porche	1/1/96	#1234567890	$50,000	$30,000
* *	*	*	#	$	$
* *	*	*	#	$	$
* *	*	*	#	$	$
* *	*	*	#	$	$
* *	*	*	#	$	$

PRIORITY DEBTS (IRS, state and local taxes etc.; include penalties)

Creditor Address:	Type of debt	Date (mo/yr) incurred	Acct.#	Balance
IRS Austin, Tx 76543	federal income tax	4/15/93	#123.45.6789	$50,000
* *	*	*	#	$
* *	*	*	#	$
* *	*	*	#	$

UN-SECURED DEBTS (credit cards, medical, personal loans etc.)

Creditor Address:	Type of Debt	Date (mo/yr) incurred	Acct.#	Balance
VISA P.O. 1234 Dallas, Tx 76543	credit card charges	1/1/90-9/1/96	#1234567890	$50,000
* *	*	*	#	$
* *	*	*	#	$
* *	*	*	#	$
* *	*	*	#	$
* *	*	*	#	$
* *	*	*	#	$
* *	*	*	#	$
* *	*	*	#	$
* *	*	*	#	$
* *	*	*	#	$
* *	*	*	#	$
* *	*	*	#	$
* *	*	*	#	$
* *	*	*	#	$
* *	*	*	#	$

SEARS (may be both secured & unsecured)

Address:	Charges: From: ____19___ To: ______19___	Acct.#	Balance $
Major Purchases	$ Value Now	Major Purchases	$ Value Now
Clothes	$ 200	486 computer	$ 350
*	$	*	$
*	$	*	$
Total Balance Due	$	***************	***************
Total Value Now -	$	=	Secured Debt
=	$	=	Unsecured Debt

ANNUAL INCOME

1/1/96- Date of Filing $________	1995 $________	1994 $________

Payments over $600 to any one creditor within the last 90 days

___Creditor_____	Acct. #	Date (mo/day/yr)	$ Paid	Balance
*	#	*	$	$
*	#	*	$	$
*	#	*	$	$

Repossessions, Attachments, Garnishments, Seizures, Foreclosures

____Creditor____	Acct.#	Date (mo/yr)	Property type	Value
*	#	*	$	$
*	#	*	$	$
*	#	*	$	$

Law suits in which debtor was or is a party within the last 1 year

Names of parties	Case #, county/state	Court	Type of suit	Complete?
*	#	*	*	__yes__no
*	#	*	*	__yes__no
*	#	*	*	__yes__no

Set Offs (by creditor, bank etc. against debtor in the last 90 days

____Creditor____	Address	Date (mo/yr)	Acct.#	Amount
*	*	*	#	$
*	*	*	#	$

Closed Financial Accounts

____Creditor____	Address	Date (mo/yr)	Acct.#	Balance
*	*	*	#	$
*	*	*	#	$

Safe Deposit Box (belonging to debtor(s)

__Institution__	Address	Contents
*	*	*
*	*	*

Charitable Contributions or Gifts Over $200 - (within the last 12 months)

Person/Group & address	Date (mo/yr)	Relationship Type of gift	Value
*	*	*	$
*	*	*	$

Other Property Transfers (within 1 yr.) Include new loans etc.)

Person/Group & address	Date (mo/yr)	Relationship Type of gift	Value
*	*	*	$
*	*	*	$

Losses from fire, theft, gambling etc. within 1 year

Description of Property	Date (mo/yr)	Circumstances	Value
*	*	*	$
*	*	*	$

Property Held for another person

Owner's Name/Address	Description of Property	Location of Property	Value
*	*	*	$
*	*	*	$

The following information is ONLY for debtor's who HAVE BEEN IN BUSINESS within THE LAST 2 YEARS

Books, Records, and Financial Statements

Debtor's Business Interests

Name of Business & Address	Nature of Business	Debtor's interest	Date Closed
*	*	*	*
*	*	*	*

bookkeepers/accountants within the last 6 years

Name of Bookkeeper/Accountant & Address	Dates of Service
*	*
*	*

Persons or firms who have prepared a financial statement or conducted an audit within the last 2 years

Name of Individual or firm & Address	Dates of Service
*	*
*	*

Persons or Firms in Possession of Records/Books

Name of Person or Firm & Address	Dates of Service
*	*
*	*

Financial institutions, creditors, or others to whom financial statement was issued within the last 2 years

Name of Person or Entity & Address	Date Issued
*	*
*	*

Inventories

Last 2 Inventories

Person Supervising	Date	$ Amount cost, market, other
*	*	*
*	*	*

Person in possession of inventory records

Name of Person & Address	Dates of Inventory
*	*
*	*

Return your completed worksheet, for processing (with the $200 processing fee in money order or cashier's check); payable to:

Your completed paperwork, ready to be signed and mailed for filing to your local bankruptcy clerk, will be return mailed to you within 5 business days of receipt with all the procedural informtion you will need to process your own bankruptcy without paying a lawyer.