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Client QuestionnaireSection 1 - Basic InformationPart A. Name and AddressMiddleLastName: FirstHave you used any other names in the past eight years?NoYesIf yes, please list other names used:Have you used any business names or Employer Identification Numbers (EIN) in the last 8 years?If yes, please list business names and/or EINs used:Telephone Numbers\Email address:Home:Work:Cell:Email:Social Security Number:Driver's License Number:Date of Birth:Address:City:State:If you have a different mailing address, please list:Mailing Address:City:State:Zip:Expiration Date:State:Zip:County:County:Have you lived at this address for at least 180 days?NoYesHave you lived at this address for at least 3 years?NoYesIf you answered no to either of the questions above, please list your previous address:Dates: FromToAddress:City:State:Zip:County:Dates: FromAddress:City:Dates: FromAddress:City:Marital Status:Never MarriedMarried and living apartCopyright (c) 1996-2015 Best Case, LLC - nty:Married and living togetherDivorcedWidowedPage 1
Part B. Name and Address of SpouseIf you are filing jointly with your spouse, fill in the following information about your spouse:MiddleLastName: FirstHas your spouse used any other names in the past 8 years?NoYesIf yes, please list other names used:Has your spouse used any business names or Employer Identification Numbers (EIN) in the last 8 years?If yes, please list business names and/or EINs used:Telephone Numbers\Email address:Home:Work:Cell:Email:Social Security Number:Driver's License Number:Expiration Date:Date of Birth:If your spouse lives at a different address, please list:Address:City:State:Zip:County:Has your spouse lived at this address for at least 180 days?NoYesHas your spouse lived at this address for at least 3 years?NoYesIf you answered no to either of the questions above, please list your previous address:Dates: FromToAddress:City:State:Zip:County:Dates: FromAddress:City:Dates: Zip:County:Part C. Prior and/or Pending Bankruptcy CasesHave you filed a bankruptcy case in the last 8 years?NoYesIf yes, in which district of which state was the case filed?Case Number:Date Filed:Date Discharged:Was the case dismissed (you did not complete the bankruptcy)?NoYesIf so, what date was it dismissed?Are any bankruptcy cases pending or being filed by your spouse, a business partner, or an affiliate?If yes, name of debtor:Relationship to you:Case Number:Copyright (c) 1996-2015 Best Case, LLC - www.bestcase.comNoYesPage 2
Date Filed:District (If known):Part D. Debtors who reside as Tenants of Residential PropertyDo you have an eviction pending against you?NoYesIf yes, please provide your landlord's name and address:Name:Address:City:State:Zip:Part E. Business Owned as a Sole ProprietorAre you the sole proprietor of a full- or part-time business?If yes, please provide the name and location of the business:Name of business:Address:City:State:Zip:Description of business:Part F. Hazardous Property or Property That Needs Immediate AttentionDo you own or have any property that needs immediate attention or that poses or is alleged to pose a threat of imminentand identifiable harm to public health or safety?NoYesIf yes, please describe the hazard:If immediate attention is needed, why is it needed?Where is the property?Address:City:State:Zip:Copyright (c) 1996-2015 Best Case, LLC - www.bestcase.comPage 3
Section 2 - Property (Schedule A/B)Separately list and describe assets in each category below. List an asset only once. If an asset fits inmore than one category, list the asset in the category where you think it fits best. If more space isneeded, attach a separate page to this questionnaire.Part A. Residence, Building, Land, Other Real EstateAddress and Descriptionof PropertyList all mortgages, home equity loansand other liens against the property:Please provide details requested below.Address:1. Who is the lender? (Name and Address)EstimatedValue ofPropertyOwned by:You, yourspouse, bothyou and yourspouse, youand at leastone personother than yourspouse.If youare notthe onlyowner:Pleaseenter the% of thepropertyyou own.Office UseOnlyExemptions?YouSpouseJointOther:What is the property? Check 2. What is the amount of the mortgage, lienall that apply.or loan?Single-family homeDuplex or multi-unitbuilding3. What is your current interest rate on theloan?Condominium orcooperative4. What is your monthly payment?Manufactured or mobilehome5. Does payment include taxes and/orNoYesinsurance?6. How many payments are left?LandInvestment propertyTimeshareOther:Address:1. Who is the lender? (Name and Address)YouSpouseJointOther:What is the property? Checkall that apply.2. What is the amount of the mortgage, lienor loan?Single-family homeDuplex or multi-unitbuilding3. What is your current interest rate on theloan?Condominium orcooperative4. What is your monthly payment?Manufactured or mobilehomeLandInvestment propertyTimeshareOther5. Does payment include taxes and/orNoYesinsurance?6. How many payments are left?Copyright (c) 1996-2015 Best Case, LLC - www.bestcase.comPage 4
Part B. Cars, Vans, Trucks, Tractors, SUVs, Motorcycles, RVs, Watercraft, Aircraft, MotorHomes, ATVs, Other VehiclesSpecify "Used value". What you would pay to buy it used, not new, considering the age andcondition.Type of PropertyVehicle #1Do you ownthis type ofproperty?NoYesVehicle #2NoYesVehicle #3NoYesWatercraft/Aircraft/MotorHomes/ATVs/Other (listyear, make, and model)DescriptionYear:Make:Model:Mileage:Names on Title:Other Information:Value ofPropertyOwned by:Office UseOnlyYou, yourspouse, both Exemptions?you and yourspouse, youand at leastone personother thanyour :Names on Title:Other leage:Names on Title:Other Information:YouSpouseJointOther:NoYesCopyright (c) 1996-2015 Best Case, LLC - www.bestcase.comYouSpouseJointOther:Page 5
Part C. Personal and Household ItemsType of PropertyDo you ownthis type ofproperty?Household Goods andFurnishings (Majorappliances, furniture, linens,china, kitchenware, etc.)NoElectronics (TVs, stereos,computers, game consoles,tablets, iPods, mobilephones, etc.)NoCollectibles of value (art,paintings, prints,memorabilia, antiques,stamp/coin/card collections,etc.)NoSports, photo, exercise, andother hobby equipment;musical instrumentsNoFirearms, ammunition, andrelated equipment (Identifyeach individual firearm)NoYesYesYesYesYesCopyright (c) 1996-2015 Best Case, LLC - www.bestcase.comDescriptionValue ofPropertyOwned by:Office UseOnlyYou, yourspouse, both Exemptions?you and yourspouse, youand at leastone personother thanyour tOther:Page 6
Type of PropertyJewelry (Divide jewelry byowner)Do you ownthis type ofproperty?NoYesPets/non-farm animalsNoYesHealth aids and all otherhousehold items not listedNoYesCopyright (c) 1996-2015 Best Case, LLC - www.bestcase.comDescriptionValue ofPropertyOwned by:Office UseOnlyYou, yourspouse, both Exemptions?you and yourspouse, youand at leastone personother thanyour SpouseJointOther:Page 7
Part D. Financial AssetsType of PropertyDo you ownthis type ofproperty?Cash (spare change/moneyin your purse or wallet, cashnot in accounts)NoChecking account #1 (listname(s) on account, bankname, and account number)NoChecking account #2 (listname(s) on account, bankname, and account number)NoSavings account #1 (listname(s) on account, bankname, and account number)NoSavings account #2 (listname(s) on account, bankname, and account number)NoCertificate of deposit (listname(s) on account, bankname, and account number)NoOther financial account #1(list name(s) on account,bank name, and accountnumber)NoOther financial account #2(list name(s) on account,bank name, and accountnumber)NoYesYesYesYesYesYesYesYesCopyright (c) 1996-2015 Best Case, LLC - www.bestcase.comDescriptionValue ofPropertyOwned by:Office UseOnlyYou, yourspouse, both Exemptions?you and yourspouse, youand at leastone personother thanyour SpouseJointOther:Page 8
Type of PropertyDo you ownthis type ofproperty?Other financial account #3(list name(s) on account,bank name, and accountnumber)NoOther financial account #4(list name(s) on account,bank name, and accountnumber)NoBonds, mutual funds, andpublicly traded stocksNoYesYesYesNon-publicly traded stocksand interests in businesses,corporations, LLCs,partnerships, and jointventures (list % ofownership)NoGovernment and corporatebonds and instruments(including U.S. SavingsBonds)NoRetirement, pension, orprofit-sharing plan #1 (IRA,401(k), 403(b), thrift savingsaccount, or other pension orprofit-sharing plan) (list typeof plan and where theaccount is held)NoRetirement, pension, orprofit-sharing plan #2 (IRA,401(k), 403(b), thrift savingsaccount, or other pension orprofit-sharing plan) (list typeof plan and where theaccount is held)NoRetirement, pension, orprofit-sharing plan #3 (IRA,401(k), 403(b), thrift savingsaccount, or other pension orprofit-sharing plan) (list typeof plan and where theaccount is held)NoYesYesYesYesYesCopyright (c) 1996-2015 Best Case, LLC - www.bestcase.comDescriptionValue ofPropertyOwned by:Office UseOnlyYou, yourspouse, both Exemptions?you and yourspouse, youand at leastone personother thanyour SpouseJointOther:Page 9
Type of PropertyDo you ownthis type ofproperty?Security deposits (typicallywith landlord or utility) (listholder)NoPrepayments (prepaid rent,layaway, gift cards, etc.)NoYesYesAnnuities (list company)NoYesEducation IRA, Sec. 529 orSec. 530 account, statetuition planNoTrusts, life estates, future,and equitable interests inproperty or assetsNoPatents, copyrights,trademarks, trade secrets,and other intellectualpropertyNoLicenses, franchises, andother general intangiblesNoYesYesYesYesTax refunds owed to you (listyears due)NoYesCopyright (c) 1996-2015 Best Case, LLC - www.bestcase.comDescriptionValue ofPropertyOwned by:Office UseOnlyYou, yourspouse, both Exemptions?you and yourspouse, youand at leastone personother thanyour SpouseJointOther:Page 10
Type of PropertyAlimony and child supportDo you ownthis type ofproperty?NoYesOther amounts someoneowes you (unpaid wages,disability benefits, sick pay,vacation pay, workers'compensation, unpaid loansmade by you, etc.)NoCash value of insurancepolicies (whole or universallife, health, disability, HSA,etc.) (list insurance companyand beneficiary)NoInheritances, estatedistributions, and deathbenefitsNoPersonal injury claims orawardsNoYesYesYesYesLawsuits or claims againstanyone for anythingAll other claims or rights tosue someoneValue ofPropertyOwned by:Office UseOnlyYou, yourspouse, both Exemptions?you and yourspouse, youand at leastone personother thanyour her:YesAny other financial asset notlistedDescriptionNoYesCopyright (c) 1996-2015 Best Case, LLC - www.bestcase.comYouSpouseJointOther:Page 11
Part E. Business-Related AssetsType of PropertyAccounts receivable orcommissions earned (list)Do you ownthis type ofproperty?NoYesDescriptionValue ofPropertyOwned by:Office UseOnlyYou, yourspouse, both Exemptions?you and yourspouse, youand at leastone personother thanyour spouse.YouSpouseJointOther:Office equipment,furnishings, and supplies(list)NoYouSpouseYesJointOther:Machinery, fixtures,equipment, businesssupplies, and tools of yourtrade (list)NoYouSpouseJointOther:Business inventory (list)NoYesYesInterests in partnerships orjoint ventures (name andtype of business, % interest)NoCustomer and mailing listsNoYesYesOther business-relatedproperty not already listedNoYesCopyright (c) 1996-2015 Best Case, LLC - Other:YouSpouseJointOther:YouSpouseJointOther:Page 12
Part F. Farm and Commercial Fishing-Related PropertyType of PropertyDo you ownthis type ofproperty?Farm animals (livestock,poultry, farm-raised fish,etc.)NoCrops (growing orharvested)NoDescriptionValue er:YesFarm and commercial fishingequipment, implements,machinery, fixtures, andtools of trade (list)NoFarm and commercial fishingsupplies, chemicals, andfeed (list)NoOwned by:Office UseOnlyYou, yourspouse, both Exemptions?you and yourspouse, youand at leastone personother thanyour YesPart G. MiscellaneousType of PropertyAll other property of any kindnot previously listedDo you ownthis type ofproperty?NoYesCopyright (c) 1996-2015 Best Case, LLC - www.bestcase.comDescriptionValue ofPropertyOwned by:Office UseOnlyYou, yourspouse, both Exemptions?you and yourspouse, youand at leastone personother thanyour spouse.YouSpouseJointOther:Page 13
Section 3 - Debts (Schedule D/E/F)Part A. Debts Secured by PropertyPlease list below all debts that you owe OR that creditors claim you owe that are secured by property.Type of DebtHome loan and/ormortgageCreditor Information1. Amount Owed (amount ofclaim):Property Information:1. Describe property:Person(s)Do youResponsible/Codebtor dispute thedebt?Who owes the debt?Self2. Creditor Name and Address:Office UseOnlyNoYesSpouseJoint3. Account Number, if any:4. Date/range of dates whendebt was incurred:2. Monthly paymentamount:3. Number of paymentsremaining:5. Contact person's name andaddress if different:Other:Is there a codebtor orcosigner on this loan?NoYesIf yes, please providename and address:Home loan and/ormortgage1. Amount Owed (amount ofclaim):1. Describe property:Who owes the debt?Self2. Creditor Name and Address:NoYesSpouseJoint3. Account Number, if any:4. Date/range of dates whendebt was incurred:5. Contact person's name andaddress if different:2. Monthly paymentamount:3. Number of paymentsremaining:Other:Is there a codebtor orcosigner on this loan?NoYesIf yes, please providename and address:Copyright (c) 1996-2015 Best Case, LLC - www.bestcase.comPage 14
Type of DebtHome loan and/ormortgageCreditor Information1. Amount Owed (amount ofclaim):Property Information:1. Describe property:Person(s)Do youResponsible/Codebtor dispute thedebt?Who owes the debt?Office UseOnlyNoSelfYesSpouse2. Creditor Name and Address:Joint2. Monthly paymentamount:Other:3. Account Number, if any:Car loans4. Date/range of dates whendebt was incurred:3. Number of paymentsremaining:1. Amount Owed (amount ofclaim):1. Describe property:Codebtor's name andaddress:Who owes the debt?Self2. Creditor Name and Address:YesSpouse2. Monthly paymentamount:JointOther:3. Account Number, if any:Car loansNo4. Date/range of dates whendebt was incurred:3. Number of paymentsremaining:1. Amount Owed (amount ofclaim):1. Describe property:Codebtor's name andaddress:Who owes the debt?Self2. Creditor Name and Address:NoYesSpouseJoint3. Account Number, if any:4. Date/range of dates whendebt was incurred:Copyright (c) 1996-2015 Best Case, LLC - www.bestcase.com2. Monthly paymentamount:3. Number of paymentsremaining:Other:Codebtor's name andaddress:Page 15
Type of DebtCar loansCreditor Information1. Amount Owed (amount ofclaim):Property Information:1. Describe property:Person(s)Do youResponsible/Codebtor dispute thedebt?Who owes the debt?Self2. Creditor Name and Address:Office UseOnlyNoYesSpouseJoint3. Account Number, if any:4. Date/range of dates whendebt was incurred:Other propertyloan1. Amount Owed (amount ofclaim):2. Monthly paymentamount:3. Number of paymentsremaining:1. Describe property:Other:Codebtor's name andaddress:Who owes the debt?Self2. Creditor Name and Address:1. Amount Owed (amount ofclaim):JointOther:3. Account Number, if any:Other propertyloansYesSpouse2. Monthly paymentamount:4. Date/range of dates whendebt was incurred:No3. Number of paymentsremaining:1. Describe property:Codebtor's name andaddress:Who owes the debt?Self2. Creditor Name and Address:NoYesSpouseJoint2. Monthly paymentamount:3. Account Number, if any:4. Date/range of dates whendebt was incurred:Copyright (c) 1996-2015 Best Case, LLC - www.bestcase.com3. Number of paymentsremaining:Other:Codebtor's name andaddress:Page 16
Part B. Credit Card DebtsPlease list below all credit card debts that you owe OR that creditors claim you owe.Type of DebtMajor credit carddebts (Visa,AmericanExpress, MasterCard, Discover)Creditor Information:1. Amount Owed (amount of claim):2. Creditor Name and Address:Person(s)Responsible/CodebtorWho incurred the debt?SelfSpouseJointOther:Codebtor's name andaddress:Do youdisputethe debt?Office Use OnlyNoYes3. Account Number, if any:4. Date/range of dates when debt was incurred:Major credit carddebts (Visa,AmericanExpress, MasterCard, Discover)1. Amount Owed (amount of claim):2. Creditor Name and Address:Who incurred the debt?SelfSpouseJointOther:Codebtor's name andaddress:NoYes3. Account Number, if any:4. Date/range of dates when debt was incurred:Major credit carddebts (Visa,AmericanExpress, MasterCard, Discover)1. Amount Owed (amount of claim):2. Creditor Name and Address:3. Account Number, if any:Who incurred the debt?SelfSpouseJointNoYesOther:Codebtor's name andaddress:4. Date/range of dates when debt was incurred:Major credit carddebts (Visa,AmericanExpress, MasterCard, Discover)1. Amount Owed (amount of claim):2. Creditor Name and Address:3. Account Number, if any:Who incurred the debt?SelfSpouseJointOther:Codebtor's name andaddress:NoYes4. Date/range of dates when debt was incurred:Copyright (c) 1996-2015 Best Case, LLC - www.bestcase.comPage 17
Type of DebtMajor credit carddebts (Visa,AmericanExpress, MasterCard, Discover)Creditor Information:1. Amount Owed (amount of claim):2. Creditor Name and Address:Person(s)Responsible/CodebtorWho incurred the debt?SelfSpouseJointOther:Codebtor's name andaddress:Do youdisputethe debt?Office Use OnlyNoYes3. Account Number, if any:4. Date/range of dates when debt was incurred:Major credit carddebts (Visa,AmericanExpress, MasterCard, Discover)1. Amount Owed (amount of claim):2. Creditor Name and Address:3. Account Number, if any:Who incurred the debt?SelfSpouseJointOther:Codebtor's name andaddress:NoYes4. Date/range of dates when debt was incurred:Department storecredit card debts1. Amount Owed (amount of claim):2. Creditor Name and Address:3. Account Number, if any:Who incurred the debt?SelfSpouseJointOther:Codebtor's name andaddress:NoYes4. Date/range of dates when debt was incurred:Department storecredit card debts1. Amount Owed (amount of claim):2. Creditor Name and Address:3. Account Number, if any:Who incurred the debt?SelfSpouseJointOther:Codebtor's name andaddress:NoYes4. Date/range of dates when debt was incurred:Copyright (c) 1996-2015 Best Case, LLC - www.bestcase.comPage 18
Type of DebtOther credit carddebts (gas cards,phone cards, etc.)Creditor Information:1. Amount Owed (amount of claim):2. Creditor Name and Address:3. Account Number, if any:Person(s)Responsible/CodebtorWho incurred the debt?SelfSpouseJointOther:Codebtor's name andaddress:Do youdisputethe debt?Office Use OnlyNoYes4. Date/range of dates when debt was incurred:Other credit carddebts (gas cards,phone cards, etc.)1. Amount Owed (amount of claim):2. Creditor Name and Address:3. Account Number, if any:Who incurred the debt?SelfSpouseJointOther:Codebtor's name andaddress:NoYes4. Date/range of dates when debt was incurred:Other credit carddebts (gas cards,phone cards, etc.)1. Amount Owed (amount of claim):2. Creditor Name and Address:3. Account Number, if any:Who incurred the debt?SelfSpouseJointOther:Codebtor's name andaddress:NoYes4. Date/range of dates when debt was incurred:Other Debt1. Amount Owed (amount of claim):2. Creditor Name and Address:3. Account Number, if any:Who incurred the debt?SelfSpouseNoYesJointOther:Codebtor's name andaddress:4. Date/range of dates when debt was incurred:Copyright (c) 1996-2015 Best Case, LLC - www.bestcase.comPage 19
Part C. Medical DebtsPlease list below all unpaid medical bill debts that you owe OR that creditors claim you owe.Type of DebtUnpaid medicalbillsCreditor Information:1. Amount Owed (amount of claim):2. Creditor Name and Address:Person(s)Responsible/CodebtorWho incurred the debt?SelfSpouseJointOther:Do youdisputethe debt?Office Use OnlyNoYes3. Account Number, if any:Unpaid medicalbills4. Any additional information about the debt:Codebtor name andaddress:1. Amount Owed (amount of claim):Who incurred the debt?2. Creditor Name and Address:3. Account Number, if any:SelfSpouseJointOther:NoYesCodebtor name andaddress:4. Any additional information about the debt:Unpaid medicalbills1. Amount Owed (amount of claim):2. Creditor Name and Address:Who incurred the debt?SelfSpouseJointOther:NoYes3. Account Number, if any:Unpaid medicalbills4. Any additional information about the debt:Codebtor name andaddress:1. Amount Owed (amount of claim):Who incurred the debt?2. Creditor Name and Address:SelfSpouseJointOther:NoYes3. Account Number, if any:4. Any additional information about the debt:Copyright (c) 1996-2015 Best Case, LLC - www.bestcase.comCodebtor name andaddress:Page 20
Part D. Tax DebtsPlease list below all unpaid tax debts that you owe OR that creditors claim you owe.Type of DebtUnpaid taxesCreditor Information:1. Amount Owed (amount of claim):2. Creditor Name and Address:3. Account Number, if any:Person(s) Responsible/CodebtorWho incurred the debt?SelfSpouseJointOther:Do youdisputethe debt?Office Use OnlyNoYesCodebtor name andaddress:4. Tax Year5. Type of taxUnpaid taxes1. Amount Owed (amount of claim):2. Creditor Name and Address:3. Account Number, if any:Who incurred the debt?SelfSpouseJointOther:NoYesCodebtor name andaddress:4. Tax Year5. Type of taxUnpaid taxes1. Amount Owed (amount of claim):2. Creditor Name and Address:3. Account Number, if any:Who incurred the debt?SelfSpouseJointOther:NoYesCodebtor name andaddress:4. Tax Year5. Type of taxCopyright (c) 1996-2015 Best Case, LLC - www.bestcase.comPage 21
Part E. Student Loan DebtsPlease list below all Student Loan debts that you owe OR that creditors claim you owe.Type of DebtStudent loanCreditor Information:1. Amount Owed (amount of claim):2. Creditor Name and Address:3. Account Number, if any:Person(s)Responsible/CodebtorWho incurred the debt?SelfSpouseJointOther:Do youdisputethe debt?Office Use OnlyNoYesCodebtor name andaddress:4. Any additional information about the debt:Student loan1. Amount Owed (amount of claim):2. Creditor Name and Address:3. Account Number, if any:Who incurred the debt?SelfSpouseJointOther:NoYesCodebtor name andaddress:4. Any additional information about the debt:Student loan1. Amount Owed (amount of claim):2. Creditor Name and Address:Who incurred the debt?SelfSpouseJointNoYesOther:3. Account Number, if any:Codebtor name andaddress:4. Any additional information about the debt:Copyright (c) 1996-2015 Best Case, LLC - www.bestcase.comPage 22
Part F. Other DebtsPlease list below all debts not listed above that you owe OR that creditors claim you owe.Please Describe theType of Debt(i.e. unpaid rent, alimonyor child support, servicefees, other bank loans,personal loans, or entera description of yourown.)Describe:Creditor Information:1. Amount Owed (amount of claim):2. Creditor Name and Address:3. Account Number, if any:Person(s)Responsible/CodebtorWho incurred the debt?SelfSpouseJointOther:Codebtor's name andaddress:Do youdisputethe debt?Office Use OnlyNoYes4. Date/range of dates when debt wasincurred:Describe:1. Amount Owed (amount of claim):2. Creditor Name and Address:3. Account Number, if any:Who incurred the debt?SelfSpouseJointOther:Codebtor's name andaddress:NoYes4. Date/range of dates when debt wasincurred:Describe:1. Amount Owed (amount of claim):2. Creditor Name and Address:3. Account Number, if any:Who incurred the debt?SelfSpouseJointOther:Codebtor's name andaddress:NoYes4. Date/range of dates when debt wasincurred:Copyright (c) 1996-2015 Best Case, LLC - www.bestcase.comPage 23
Section 4 - Unexpired Leases and Contracts (Schedule G)List below any leases or contracts that are still current and to which you are a party. Include residential, car and businessleases, and service or business contracts.Description of Lease or ContractCopyright (c) 1996-2015 Best Case, LLC - www.bestcase.comName and Address of Other Party or Parties Date ContractExpiresOffice Use OnlyPage 24
Section 5 - Current Income (Schedule I)Part A. Debtor's Employer InformationName and Address of your employer:How long have you been employed at this job:Occupation (please state job title or provide brief description):Second employer (if applicable):Name and Address of your Second employer:How long have you been employed at this second job:Occupation (please state job title or provide brief description):Notes:Part B. Joint Debtor's (Spouse's) Employer InformationName and Address of your spouse's employer:How long has spouse been employed at this job:Occupation (please state job title or provide brief description):Second employer (if applicable):Name and Address of your spouse's Second employer:How long has spouse been employed at this second job:Occupation (please state job title or provide brief description):Do you receive income from business operations outside of your regular paycheck listed above?NoYesIf yes, how much do you receive per month?Do you receive income from interest or dividends outside of your regular paycheck listed above?NoYesIf yes, how much do you receive per month?Do you receive income from alimony or family support payments for your use or for the care of yourdependents?NoYesIf yes, how much do you receive per month?Copyright (c) 1996-2015 Best Case, LLC - www.bestcase.comPage 25
Do you receive income from Unemployment?NoYesIf yes, how much do you receive per month?Do you receive income from Social Security?NoYesIf yes, how much do you receive per month?Do you receive monetary government assistance?NoYesIf yes, please describe:How much do you receive per month?Do you receive retirement or pension money?NoYesIf yes, how much do you receive per month?Do you have any other source of income not listed?NoYesIf yes, please describeHow much do you receive per month?Are you expecting any increase or decrease in salary next year?NoYesIf yes, please describePart D. Joint Debtor's (Spouse's) Wage InformationWhat is the gross amount of your paycheck, before taxes/other deductions are taken out?How often do you get paid?once a weekevery two weekstwice a monthonce a monthotherWhat is your estimated overtime pay per month?How much is taken out of each paycheck for taxes, Medicare, and social security? (combined total)How much is taken out of each paycheck for Mandatory Contributions to Retirement?How much is taken out of each paycheck for Voluntary Contributions to Retirement?How much is taken out of each paycheck for Required Repayments of Retirement fund Loans?How much is automatically deducted for insurance?How much is taken out for alimony or family support for the care of your dependents?How much is deducted for union dues?Other Deduction (describe):Other Deduction (describe):Other Deduction (describe):Do you receive income from business operations outside of your regular paycheck listed above?NoYesIf yes, how much do you receive per month?Do you receive income from interest or dividends outside of your regular paycheck listed above?NoYesIf yes, how much do you receive per month?Do you receive income from alimony or family support payments for your use or for the care of yourdependents?NoYesIf yes, how much do you receive per month?Copyright (c) 1996-2015 Best Case, LLC - www.bestcase.comPage 26
Do you receive income from Unemployment?NoYesIf yes, how much do you receive per month?Do you receive income from Social Security?NoYesIf yes, how much do you receive per month?Do you receive monetary government assistance?NoYesIf yes, please describe:How much do you receive per month?Do you receive retirement or pension money?NoYesIf yes, how much do you receive per month?Do you have any other source of income not listed?NoYesIf yes, please describeHow much do you receive per month?Are you expecting any increase or decrease in salary next year?NoYesIf yes, please describePart E. Debtor's Current Monthly Income CalculationFill in your monthly income for the categories below in the column labeled "Month 1." If your income for one of the belowcategories varies from month to month, complete the below chart by entering in your income for all six months.Month 1(last month)Month 2(2 months ago)//Month 3Month 4Month 5Month 6////For OfficeUse OnlyIncome fromoperation ofbusiness:a. Gross Income- b. Expenses c. Net Income.Rent and other realproperty income::a. Gross Income- b. Expenses c. Net Income.Interest, dividends,and royalties.Pension andretirement incomeRegularcontributions fromothers to thehouseholdexpenses, includingchild support.UnemploymentCompensation.Social SecurityCopyright (c) 1996-2015 Best Case, LLC - www.bestcase.comPage 27
income.Other sources notalready mentioned.Describe:Part F. Joint Debtor's (Spouse's) Current Monthly Income CalculationFill in your monthly income for the categories below in the column labeled "Month 1." If your income for one of the belowcategories varies from month to month, complete the below chart by entering in your income for all six months.Mo
Part C. Prior and/or Pending Bankruptcy Cases Have you filed a bankruptcy case in the last 8 years? No Yes If yes, in which district of which state was the case filed? Case Number: Date Filed: Date Discharged: Was the case dismissed (you did not complete the bankruptcy)? No Yes If so, what date was it dismissed?
