INSTRUCTIONS AND DEFINITIONS:

Completion of this Statement is required if you desire to file bankruptcy.  If you are filing jointly with your spouse, include information for both you and your spouse on this form.  If you are filing under Chapter 13, and you are married and not separated from your spouse, you must provide information about your spouse even if you are not filing jointly with your spouse.  If you are separated from your spouse and not filing jointly, you are not required to provide information for your spouse. 

An individual debtor engaged in business as a sole proprietor, partner, family farmer, or self-employed professional, should provide the information requested on this statement concerning all such activities as well as the individual's personal affairs.

"In business" - An individual debtor is "in business" for the purpose of this form if the debtor is or has been within six years immediately preceding the filing of this bankruptcy case, any of the following:  an officer, director, managing executive, or owner of 5 percent or more of the voting or equity securities of a corporation; a partner, other than a limited partner, or a partnership; a sole proprietor or self-employed full-time or part-time.  An individual debtor also may be "in business" for the purpose of this form if the debtor engages in a trade, business or other activity, other than as an employee, to supplement income of the debtor's primary employment.

Do not include the name or address of a minor child in this statement.  Indicate payments, transfers and the like to minor children by stating "a minor child."

"Insider" - The term "insider" includes but is not limited to:  relatives of the debtor, general partners of the debtor and their relatives; corporations of which the debtor is an officer, director, or person in control; affiliates of the debtor and insiders of such affiliates; any managing agent of the debtor.


If you have no information to report for a question, check the "NONE" box.

1.    INCOME FROM EMPLOYMENT OR OPERATION OF BUSINESS.  State the annual gross income you have received from employment, trade or profession, or from operation of the debtor's business, including part-time activities either as an employee or in independent trade or business.     NONE 

2.    INCOME OTHER THAN FROM EMPLOYMENT OR OPERATION OF BUSINESS.  State the amount of income received from sources other than employment, trade, profession or operation of the debtor's business during the TWO YEARS immediately preceding the commencement of this case (including child support, tax refunds, pension income, unemployment compensation, social security, 401K/IRA withdrawal, etc.)   NONE 

3.    PAYMENTS TO CREDITORS.  
        a./b.  For individual or joint debtor(s) with primarily consumer debts, list all payments on loans, installment purchases of goods or services, and other debts to any creditor made within 90 days immediately preceding the commencement of this case if the aggregate value of all property that constitutes or is affected by such transfer is not less than $600.00.  Example:  If you make monthly payments of $200 to XYZ Credit Card Co., the total payments within 90 days prior to filing (3 months), would be $600 and you would need to disclose payments to that creditor.  Usually payments on home mortgages and car loans exceed a total of $600 in the 90 days prior to filing and need to be listed.  (Include payments, if any, to a creditor for a domestic support obligation, or as part of a debt repayment schedule under a plan by an approved nonprofit budgeting and creditor counseling agency.)  For debtors whose debts are not primarily consumer debts, list each payment or other transfer to any creditor made within 90 days prior to filing if the aggregate value of all property that constitutes or is affected by such transfer is not less than $5,000. 
NONE     

c.  List all payments made within ONE YEAR immediately preceding the commencement of this case to or for the benefit of creditors who are or were "insiders" as defined above.  NONE

5.    REPOSSESSIONS, FORECLOSURES, AND RETURNS.  List all property that has been repossessed by a creditor, sold at a foreclosure sale, transferred through a deed in lieu of foreclosure, or returned to the seller, within ONE YEAR preceding the commencement of this case.     NONE

11.    CLOSED FINANCIAL ACCOUNTS.  List all financial accounts and instruments held in your name or for your benefit which were closed, sold, or otherwise transferred within ONE YEAR immediately preceding the commencement of this case.  Include checking, savings or other financial accounts, certificates of deposit, or other instruments; shares and share accounts held in banks, credit unions, pension funds, cooperatives, associations, brokerage  houses and other financial institutions.   
NONE

15.    PRIOR ADDRESSES.  If you have moved within THREE YEARS immediately preceding the commencement of this case, list all premises which the debtor occupied during that period and vacated prior to the commencement of this case.  r

PLEASE RESPOND "YES" OR "NO" TO THE REMAINING QUESTIONS ON THIS FORM.  WE WILL NOTE ALL OF YOUR AFFIRMATIVE RESPONSES AND DISCUSS THE DETAILS WITH YOU AT YOUR OFFICE CONSULTATION.

4.    SUITS AND ADMINISTRATIVE PROCEEDINGS, EXECUTIONS, GARNISHMENTS AND ATTACHMENTS.

        a.    Are you presently, or have you been within ONE YEAR prior to the commencement of this case, a party to a law suit or administrative proceeding?  
YES   NO         

        b.    Has any of your property been garnished, seized, or attached under any legal or equitable process within ONE YEAR immediately preceding the commencement of this case?  
YES   NO               

6.     ASSIGNMENTS AND RECEIVERSHIPS.  

        a.    Have you assigned any property to or for the benefit of creditors within 120 days immediately preceding the commencement of this case?    
YES NO
        b.    Has a custodian, receiver, or court-appointed receiver held property of yours within one year immediately preceding the commencement of this case?    
YES NO        

7.    GIFTS.  Have you given gifts or made charitable contributions (including tithing or donations to your church) within ONE YEAR preceding the commencement of this case other than ordinary and usual gifts to family members aggregating less than $200 in value per individual family member and charitable contributions aggregating less than $100 per recipient?    
YES NO         
        If your response to this question is affirmative, please complete the following with respect to your payment of tithing or other donations to your church or religious affiliation:

8.    LOSSES.  Have you had losses from fire, theft, other casualty or gambling within ONE YEAR immediately preceding the commencement of this case or since the commencement of this case? 
YES NO         

9.    PAYMENTS RELATED TO DEBT COUNSELING OR BANKRUPTCY.  Have payments been made or property transferred by or on your behalf to any persons, including attorneys, for consultation concerning debt consolidation, relief under the bankruptcy law or preparation of a petition in bankruptcy within ONE YEAR immediately preceding the commencement of this case?    
YES NO  

10.    OTHER TRANSFERS.  Have you transferred property, other than property transferred in the ordinary course of your business or financial affairs, either absolutely or as security for any debt, within TWO YEARS immediately preceding the commencement of your case?    
YES NO        
Have you transferred property within TEN YEARS immediately preceding the commencement of this case to a self-settled trust or similar device of which the debtor is a beneficiary?
YES NO

12.    SAFE DEPOSIT BOXES.    Do you now, or have you had within the past ONE YEAR a safe deposit or other box or depository in which you have or have had securities, cash, or other valuables?   
YES NO

13.    SETOFFS.    Has any creditor, including a bank, made any setoff against a debt or deposit of yours within 90 days preceding the commencement of this case?    
YES NO        

14.    PROPERTY HELD FOR ANOTHER PERSON.  Do you hold or have control over property that is owned by another person?  (For example, is someone letting you use their car or other asset?) 
 YES NO

16.    SPOUSES AND FORMER SPOUSES.  In the EIGHT YEARS immediately preceding the commencement of your case, have you resided with your spouse or former spouse in a community property state, commonwealth or territory (including Alaska, Arizona, California, Idaho, Louisiana, Nevada, New Mexico, Puerto Rico, Texas, Washington or Wisconsin)?
 YES NO

17.    ENVIRONMENTAL INFORMATION.  For purposes of the following questions, the following definitions apply:
"Environmental Law" means any federal, state, or local statute or regulation regulating pollution, contamination, releases of hazardous or toxic substances, wastes or material into the air, land, soil, surface water, groundwater, or other medium, including, but not limited to, statutes or regulations regulating the cleanup of these substances, wastes, or material.
"Site" means any location, facility, or property as defined under any Environmental Law, whether or not presently or formerly owned or operated by the debtor, including, but not limited to, disposal sites.
"Hazardous Material" means anything defined as a hazardous waste, hazardous substance, toxic substance, hazardous material, pollutant, or contaminant or similar term under an Environmental Law.

a.    Have you received notice in writing by a governmental unit that a site may be in violation of an Environmental Law?
 YES NO
b.    Have you provided notice to a governmental unit of a release of Hazardous Material?
 YES NO
c.    Have you been a party to any judicial or administrative proceeding under any Environmental Law?
 YES NO

18.    DEBTORS ENGAGED IN BUSINESS.  Are you now or have you within the past SIX YEARS, been a sole proprietor; or self-employed in a trade, profession or other activity either full-time or part-time; or been involved in a corporation as an officer, director, partner, managing executive, or owner of 5 percent or more of the voting or equity securities; or been a partner in a partnership?
YES NO    

YOU HAVE COMPLETED THIS FORM.  PRESS THE SUBMIT BUTTON ONLY ONCE BELOW TO SEND DIRECTLY TO OUR OFFICES.  THEN PROCEED ON TO FORM 4.  (YOU CAN COMPLETE THE FORMS AT A LATER SITTING IF YOU DESIRE)