DEPENDENTS AND INCOME Please Circle one: Single – Married – Divorced – Separated – Widowed Household Size List all dependents of you and your spouse (even if they do not live with you), their ages, and their relationship to you. Full Name of Dependent Age Relationship Occupation Spouse’s Occupation Length of Employment Length of Employment Name and Address of your employer Name and Address of spouse’s employer $ per hour hours/wk $ per hour hours/wk union dues health ins union dues health ins. Do you or your spouse Alimony Yes – No If yes, Monthly amount? receive additional Child Support Yes – No If yes, monthly amount? income from: Social Security Yes – No If yes, monthly amount? SS for children Yes – No If yes, monthly amount? Link/Food Stamps Yes – No If yes, monthly amount? Retirement Yes – No If yes, monthly amount? Pension Yes – No If yes, monthly amount? Business Yes – No If yes, monthly amount? Real Estate/ rent Yes – No If yes, monthly amount? Interest Yes – No If yes, monthly amount? Other Yes – No If yes, monthly amount? Please remember to provide our office with your 2 most recent pay-stubs and your spouse’s 2 most recent pay-stubs.
Please answer the following questions completely and to the best of your ability. Have you paid any one creditor that is not your mortgage or car loan, $500.00 or more within the last 4 months? Yes- No Have you been garnished in the last 4 months? Yes- No Have you paid off a credit card balance with a different credit card? Yes- No Have you made purchases with or taken cash from any credit card in the last 3 months? Yes - No Has anyone repossessed or foreclosed on your house or your car within the last year? Yes – No Are you suing someone or is anyone suing you? Yes – No Has your landlord threatened to or started eviction proceedings against you? Yes – No Are any of your debts due to gambling or theft by another? Yes – No Have you lost property due to a fire in the last year? Yes - No Have you given a gift of more than $200.00 within the last two years to any one individual? Yes – No Have you given an item of property valued at over $200 to anyone person within the last two years? Yes – No Have you paid back any relative money borrowed from them in the last 2 years? Yes - No Have you closed any bank accounts within the last year? Yes – No Do you have any safety deposit boxes? Yes – No Have you lived at your address for the last two years? Yes – No Have you owned any real estate (house or land) in the last four years? Yes – No Have you ever lived in a community property state, for example California, Arizona, or Alaska? Yes – No Do you owe child support, alimony, maintenance? Yes – No Have you ever been married? Yes – No Do you have a loan with a check into cash business? Yes – No Have you used personal property (TV, DVD etc.) as collateral for a loan? Yes – No Did you borrow money from anyone to pay for our services? Yes – No Is someone else paying for your bankruptcy fees? Yes - No HOW DID YOU HEAR ABOUT MY OFFICE? Yellow Pages-American Classified-Friend or Family NOTICE: Information that you provide during your case may be audited pursuant to provisions of the Bankruptcy Code. Failure to provide such information may result in dismissal of the case this title or other sanction, including criminal sanctions.