LOM Questionaire

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Law Office of MELISSA A. RASKEY Attorney At Law

Mailing Address: PO Box 5316, Hemet, California 92544
Physical Address: 27186 Newport Rd. Ste. 2, Menifee, CA 92586
Telephone: (866) 411-6659 • Facsimile: (866) 612-1595

Q U E S T I O N N A I R E

Though it may be difficult to answer the personal questions in this booklet, this office needs your answers to complete the bankruptcy documents and to properly advise you of your rights and responsibilities. As with all communications between you and anyone in our office, the information you supply is CONFIDENTIAL. Never keep information from us because you are afraid or embarrassed; to properly advise you, we must have ALL the facts.


Please complete the following questionnaire using your best efforts. If you are married and living with your spouse please include all information as to your spouse as well, even if you are filing alone. If you believe any question does not apply to you, please mark “N/A”; do not skip it. Please be certain to answer each question completely. If space is inadequate, please attach additional sheets.


If you are uncertain as to the meaning of a question or your answer to it, please so indicate by marking the question or answer with a “?” in the margin next to it.


After you have completed the questionnaire, please sign and date it. Your answers will be used to complete your bankruptcy petition to be filed with the court. Although it is possible to change or amend the petition after it is filed, it is much easier and less expensive to file a complete and accurate petition from the beginning. In order to charge our Clients a reduced fee to file a bankruptcy petition, we ask that you provide COPIES of all the documents listed below so we do not have to charge you a copy charge.


Please print and write clearly!


Documents To Be Provided (new bankruptcy law requirements; provide all that apply):

INCOME & DEDUCTIONS All Papers regarding your Income and Deductions for the past six (6) months including:

a. Paycheck stubs (including commissions and bonuses)

b. Any unemployment benefits, child or spousal support, Social Security payments, bank interest income, stock dividend income, pension or retirement income, rental income, or any other income received

c. Papers regarding any retirement contributions, insurance deductions, or other paycheck deductions

FINANCES- All papers regarding your expenses and assets including:

a. Monthly bank statements for the past six (6) months

b. Tax Returns for the past two (2) years. If a Chapter 13, four (4) years tax returns are required. BOTH FEDERAL AND STATE.

c. Papers regarding any real property owned in the past ten (10) years

d. A recent credit report (Go to www.annualcreditreport.com for free copy).

e. Copy of DMV registration or certificates of title for all vehicles and/or any all terrain, recreational vehicles etc.

f. All of the most recent creditor statements you have in your possession including, but not limited to, mortgage statements and motor vehicle statements

Copy of your certificate of counseling certificate from www.abacus.org, bothcourses.com, www.a123cc.org, www.accesscounseling.inc.

g. After we file your bankruptcy petition you will need to take a second course titled “financial management course”.

PAPERWORK REQUIRED

Paperwork Required (ADDITIONAL PAPERWORK MAYBE REQUIRED ONCE WE REVIEW YOUR MATTER)

• 2 years tax returns (Federal and State)

• Proof of income for 6 months from all sources. i.e., 6 months paystubs, SS income, pension income, VA income, unemployment, rental income etc. If self-employed 1 year profit and loss for business.

• 3 months bank statements for all accounts including online accounts such as coinbase, venmo, apple and paypal

• KBB.com on vehicle(s) using private party value only and proof of insurance (Declarations page)

• Statement for any retirement accounts i.e pension, ira, strs etc

• Statement for any Life insurance policies

• Copy of registration for vehicles

• Any pending lawsuits, if any

• Copies of creditor statements if you retained. You can hold on this and review credit report.

• Copy of divorce decree, if any

• If you rent, a copy of the lease agreement and security deposit, if any

• IF YOU OWN A HOME A COPY OF THE CURRENT MORTGAGE STATEMENT, COPY OF DEED IF POSSIBLE AND VALUE PER LOCAL REALTOR IN WRITING OR USE THE ONLINE PLATFORM WWW.ZILLOW.COM

• Clear copy of your driver’s licenses and social security cards

• If you are self-employed, we will need additional documents and will advise you once we review your information.

PERSONAL INFORMATION

Full Name
Full Name
Social Security Number:
Birth date:
MM slash DD slash YYYY
Age
Spouse’s Full Name
(PLEASE LIST YOUR MIDDLE NAME IF YOU HAVE ONE)
Spouses Social Security Number
Birth date:
MM slash DD slash YYYY
Age
Email Address:
List any alternative names (full names) you or your spouse has used in the past 8 years (e.g. maiden name):
Marital Status:
Address
City & Zip/Code
Spouse’s Home Address (if different):
City & Zip/Code
City & Zip/Code
Where else have you lived in the last Two years (if any):
Home Address:
Home Address:
II. RELATED CASE INFORMATION
Have you ever filed Bankruptcy before?
Type of case:
Location:
Was a discharge granted :
III. REAL PROPERTY
Have you owned any real property in the last 10 years?
Have you ever had your name on title of the home you rent now?
Do you own any real property?
Is the property your residence?
Is it your intension to keep this property?
PERSONAL PROPERTY

Please list the fair market value of your personal property, not what you paid for it, but the amount it would sell for if you had to sell it today at a garage sale or auction. (Exemption 703.140)

Checking/Savings accounts. List bank name, address, account number, and balance of account:

Name

List all household goods and furnishings including audio, video and computer equipment with corresponding values for each item (attach extra pages if necessary) i.e.

Dining room set, Living room set, Hutch, Three bedroom sets, dishware, 2 televisions, 2 DVD players, gardening tools, carpentry tools, tool chest, WII game system console, China set, pool table, etc :
Automobiles/Trucks/Motorcycles:

List year, make, model and value of each vehicle (e.g.: 1999 Ford Taurus $7,000). Please use NADA guide online or Kelley Blue Book online to get the estimated value of the vehicle. Print the Value you find and return it to our office with this questionnaire:

List name of lender and amount owed for each vehicle:

Auto #1:
Name of Lender:
Are you current?
Auto #2:
Name of Lender:
Are you current?
Auto #3:
Name of Lender:
Are you current?
Do you own any:
Value
Explain

INSTRUCTIONS FOR COMPLETING LIST OF CREDITORS

WE WILL RUN YOUR CREDIT REPORT SO YOU CAN LEAVE THIS SECTION BLANK OR ONLY WRITE IN THE CREDITORS YOU KNOW DO NOT SHOW UP ON YOUR CREDIT REPORT. ONCE WE SEND YOUR PETITION TO YOU FOR YOUR REVIEW IT WILL BE YOUR RESPONSIBLILITY TO CONFIRM THAT ALL OF YOUR CREDITORS ARE LISTED.

When you list your creditors, list ALL of them, even those you intend to pay. Failure to do so can be very dangerous.

List their names and addresses (including zip codes) in full. Even if you dispute a debt or a part of the debt, list the total amount that you owe or list the approximate bamount if you are unsure, BUT DO NOT ESTIMATE TOO LOW. Be sure to show the date each debt was incurred, and the nature or purpose of the debt (e. g. “medical bill”, “washer and dryer”, or purchase of a 1995 Chevrolet”).

If a collection agency or lawyer has been in touch with you about a debt that you originally owed to someone else, list the name of the original creditor, the collection agency, the lawyer, the finance company, or anyone else who has communicated with you about the debt.

An unsecured creditor is one who has no security interest for this loan other than your general assets.

A secured creditor is one who is in a position to take property away from you because you made an agreement permitting them to take this property should you default on the terms of the contract. Examples of secured creditors are the holders of your home mortgage, the company that financed your car, and most purchases made through finance companies.

If you owe more than one debt to the same creditor include information about each individual debt.

Often the right of the original creditors to collect the money or property is transferred by them to another party known as the “assignee” of your creditor. This assignee may be a collection agency, a finance company, bank, or other business. If you are now or ever have been making payments to anyone other than your original creditor, list the creditor and ALL others to whom you have made payments.

Unfortunately, few people realize how many creditors they have. For example, if a debt has been assigned, as explained above, the party to whom the debt was originally owed is a creditor and so is the party who had attempted to collect the debt, e. g., a collection agency, or an attorney. All should be listed.

TAKE YOUR TIME!! Any debt that you do not list may not be discharged in bankruptcy. List even debts that you intend to pay, and even debts someone claims you owe that you claim you do not owe. Inaccurate or incomplete answers may result in complete loss of your right to discharge in bankruptcy. List addresses accurately, along with zip codes. A creditor, who is not notified of the bankruptcy, is not bound by it and therefore will may ignore your bankruptcy. Our office cannot be held responsible for ANY CREDITORS you did not list on this QUESTIONNAIRE.

Creditor’s Name and Address

Name
Address
Creditor’s Name and Address
Has creditor taken any action?

Collection Agency, if any

Name
Address
What is debt for?
Secured Options:
Collection Agency
Name
Address

Creditor’s Name and Address

Name:
Address
Creditor’s Name and Address
Has creditor taken any action?

Collection Agency, if any

Name
Address
What is debt for?
Secured Options
Collection Agency, if any
Name
Address

Creditor’s Name and Address

Name
Address
Creditor’s Name and Address
Has creditor taken any action?

Collection Agency, if any

Name
Address
What is debt for?
Secured Options:
Untitled
Name
Address

V. INCOME and EXPENSES PLEASE LIST NAMES AND AGES OF DEPENDENTS CLAIMED:

Name
Name:
Name:
Name
Name
City/State/Zip
City/State/ZIP

PLEASE LIST YOUR CURRENT INCOME AND DEDUCTIONS

Debtor (1)
Debtor (2)
MONTHLY INCOME:
ESTIMATED OVERTIME DEDUCTIONS FROM CHECK:
ALL TAXES/SS
INSURANCE
UNION DUES
401k
OTHER:
INCOME FROM REAL PROPERTY
INTEREST & DIVIDENDS
CHILD SUPPORT/ALIMONY

RECEIVED FOR Debtor (1) dependent:

Name
Name

RECEIVED FOR Debtor (2) dependent:

Name
Name
SOCIAL SECURITY & GOV’T ASSISTANCE
PENSION & RETIREMENT
OTHER INCOME RECEIVED:
Will there be any changes in your income in the within the next year please explain:

LIST ALL YOUR MONTHLY EXPENSES

RENT\MORTGAGE PAYMENT(s):
PROPERTY TAXES: *
PROPERTY INSURANCE: If not included in mortgage payment UTILITIES:*
UTILITIES:
ELECTRICITY\NATURAL GAS:
WATER\SEWER\GARBAGE:
TELEPHONE:
CELL PHONE:
PROPANE:
SECURITY:
CABLE, SATELLITE:
INTERNET:
HOME MAINTENANCE:
CLOTHING:
FOOD:
LAUNDRY\DRY CLEANING:
MEDICAL & DRUG:
AUTO (gas & repairs):
RECREATION\NEWSPAPER:
CONTRIBUTIONS (Church, etc.):
INSURANCE:
RENTERS:
LIFE:
HEALTH*
VEHICLE:
OTHER: If not deducted from wages**
VEHICLE PAYMENT:
VEHICLE REGISTRATION: Divide yearly registration by twelve **
CHILD\SPOUSAL SUPPORT
Name
Name
Name
DAY CARE\ BABYSITTING:
CONTINUING EDUCATION:
PARKING:

AVERAGE MONTHLY BUSINESS INCOME AND EXPENSE STATEMENT

PLEASE NOTE: TO BE FILLED OUT ONLY IF YOU ARE SELF-EMPLOYED-You must also provide a 6 month profit and loss statement!

Debtor Name:
RECEIPTS
Gross Sales/Gross Fees:
Collection on Account Receivable:
Rents:
Other:
TOTAL INCOME:
COST OF SALES
Materials and Supplies:
TOTAL COST OF GOODS SOLD
GROSS PROFIT:
OPERATING EXPENSES
Net Wages:
Payroll Taxes:
Estimated Tax Payments:
Rent/Mortgage/Lease:
Business Taxes/Licenses/Permits:
Repairs/Maintenance:
Fuel/Transportation Costs:
Equipment & Tools (Purchase/Lease):
Dues/Subscriptions:
Insurance:
Office Supplies/Postage:
Advertising:
Utilities:
Telephone:
Outside Services
(Bookkeeping/Legal/Janitorial/Cleaning):
Other (Attach breakdown):
TOTAL OPERATING EXPENSES:
NET PROFIT/LOSS:

VI. FINANCIAL AFFAIRS

1. List gross income (before taxes) from work for the following years:
List Spouse’s gross income (before taxes) from work for the following years:
2. List income you may have received from other sources including disability, alimony, unemployment etc. for the following years and specify source:
Your Spouse: List income may have received from other sources including disability, alimony, unemployment etc. for the following years and specify source:
Have you paid any creditor more than $600 in the past 90 days:
Have you made payments to creditors for a business in the last 90 days?
Have you repaid any family member inside creditor for any amount in the past year?
Are you being sued or are you suing anyone?
Have you had any property attached, garnished or seized in the last year?
Have you had any Repossessions or Voluntary Returns in the last year?
Name of Creditor:
Creditor Address:
Name of Creditor:
Creditor Address:
Describe any assignment of property for the benefit of creditors made within the last 120 days:
List all property which has been in the hands of a custodian or receiver within the last year:
Have you given a gift or charitable contribution in the last year?
Have you suffered any losses from Fire, Theft, Gambling, etc. in the past year:
MM slash DD slash YYYY
Have you transferred any property to any other person in the last 2 years:
MM slash DD slash YYYY
List all Financial Accounts that you have closed in the past year (if any:
Do you have any Safe Deposit Box?
Are you holding any property for anyone else?
Have you been subject to violation of any environmental laws, (contamination, pollution, release of hazardous materials):
Have you been in business for yourself in the past 2 years:
Have you been in business or a partnership with someone else in the past 6 years:
Have you co-signed for any property that is not yet paid off?
If yes, please provide name and address of the person you co -signed for:
Name
Address/State/Zip
Note: Don’t forget to add this creditor to your “List of Creditors”
Please sign to acknowledge:

I/We have reviewed the foregoing information, and to the best of my/our knowledge, it is complete and correct.

MM slash DD slash YYYY
MM slash DD slash YYYY
Max. file size: 32 MB.

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