420 N. Roosevelt Ave., Suite 110, Burlington, IA 52601 craylawfirm@craylawfirm.com

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Client Bankruptcy Information Sheet

Thank you for choosing our law firm to assist you with your financial needs. Please fill out this form with as much details as possible. If a question or section does not apply to you, please write N/A in the space (N/A means Not Applicable). Please provide as much information as possible. All information you provide will be kept in the strictest confidence. When you have finished filling out this form, return it for the attorney to review. We look forward to helping you.

Today's _________________________________ Total Number of People Date Living in Your Household _________________

Your Name _______________________________________________________________________ First Middle Last

Date of Birth _________________________ Social Security Number ________________________

Address ________________________________________________________________________

City ________________________________ State ______________ Zip code _________________

County of Residence______________________ Length of Time at this Address_________________

Daytime Phone_____________________ Mobile Phone_______________ Evening Phone __________

Name of Spouse ______________________________________________________________________

First Middle Last

Date of Birth ______________________ Social Security Number ____________________________

Address ___________________________________________________________________________

City ________________________ State _______________ Zip Code ____________________

Home Phone ________________________ Work ________________ Cell ____________________

Email Address ___________________________________________________________________________

Mailing Address- if you would like any correspondence by the bankruptcy court to be sent to a different mailing address other than the physical address you provided (i.e. P.O. Box) please proved that address below: ____________________________________________________________________________ ________________________________________________________________________________________________________________________________________________________

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GENERAL INFORMATON

DEPENDENTS Name: Age Relationship to you Does this person live with you?

1.__________________________________ _______ _________________ ☐ YES ☐ NO 2. _________________________________ _______ _________________ ☐ YES ☐ NO 3.__________________________________ _______ __________________ ☐ YES ☐ NO 4.__________________________________ _______ _________________ ☐ YES ☐ NO 5.__________________________________ _______ _________________ ☐ YES ☐ NO ☐

OTHER INFORMATION

Have you or your spouse been known by any other name during the past 8 years ☐ YES ☐ NO (Example: maiden name, last name from previous marriage, legal name change, etc.) If yes, please write the NAME KNOWN AS and DATE(S) THIS NAME WAS USED below: Name Used__________________________________________ Dates Used ______________thru____________ Name Used__________________________________________ Dates Used ______________thru____________

Has your income significantly increased or decreased during the past six (6) months? If so, please provide details below: _________________________________________________________________________________________________ __________________________________________________________________________________________________ _________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________

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SCHEDULE A- YOUR REAL ESTATE INFORMATION

NOTICE: IF YOU OWN A MOBILE HOME PLEASE FILL OUT THE NEXT PAGE ☐ Please check this box if you have a Homestead exemption that exceeds 125,000.

• PLEASE USE A SEPARATE PAGES FOR EVERY SEPARATE PIECE OF REAL ESTATE THAT YOU OWN Check the type of real estate that you own: ☐ House ☐Condominium ☐Vacant Lot ☐Other Name(s) on Deed ___________________________________________________________________________________ Address of Real Estate_______________________________________________________________________________ Description of Real Estate: (Example: 1250 square foot home with 2 bedrooms, 2 baths, attaché 2 car garage on 2 acres of land with outbuildings)._______________________________________________________________________ _____________________________________________________________________________ Name of Mortgage Company: __________________________________________________________________________ Address: ___________________________________________________________________________________________ City: ______________________________________________ State: __________ Zip Code: _________________________ Account Number: ___________________________________ Origin date of Mortgage: ___________________________ What are your monthly payments? $__________________ What is the Payoff Amount: $__________________________ Are you behind on payments? ☐Yes ☐ NO If so which months: ___________________________________________ Amount needed to catch up payments? $____________________ Is this property in Foreclosure: Yes NO What year was your real estate last appraised? __________ What was the appraised value: _______________________ Do you have a 2nd Mortgage on the real estate? Yes NO (If yes, please complete the information below) Please tell us your intent for the property: Keep Surrender If in Collection, please provide a copy of the court documents you were served

SECOND MORTGAGE INFORMATION Name(s) on Deed ___________________________________________________________________________________ Name of Mortgage Company: __________________________________________________________________________ Address: ___________________________________________________________________________________________ City: ______________________________________________ State: __________ Zip Code: _______________________ Account Number: ___________________________________ Origin date of Mortgage: ___________________________ What are your monthly payments? $__________________ What is the Payoff Amount: $__________________________ Are you behind on payments? Yes NO If so which months: ___________________________________________ Amount needed to catch up payments? $____________________ What year was your real estate last appraised? __________ What was the appraised value: ________________________ Yes NO Please tell us your intent for the property: Keep Surrender

COLLECTION INFORMATION (IF APPLICABLE) Name of Collector or Attorney_____________________________________________________________________________ Address_______________________________ City___________________ State___________ Zip code_______________

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SCHEDULE A- YOUR MOBILE HOME

NOTICE: IF YOU OWN A MOBILE HOME PLEASE FILL OUT THE NEXT PAGE

Please check this box if you have a Homestead exemption that exceeds 125,000.• PLEASE USE A SEPARATE PAGES FOR EVERY MOBILE HOME THAT YOU OWN

Name(s) on Deed ___________________________________________________________________________________

Address of Mobile home______________________________________________________________________________ Are the wheels completely removed from your mobile home and it is attached to the land Yes No Does your mobile home sit in a mobile park Yes No What is the monthly lot payment? ______________________ Does your mobile home sit on a piece of land that you own? Yes No Size of land____________________________ Do you make separate payments for the land your mobile home sits on? _______________________________________ If so explain: _______________________________________________________________________________________ If you own the ground free and clear what is the resell value for this piece of land? _______________________________ Description of mobile home: (example: 28x40 double wide, 2 bedrooms, 1 bath, on wheels with skirting and steps and 1 out building shed, situated on mobile park). __________________________________________________________ __________________________________________________________________________________________________ Name of Mortgage Company: _________________________________________________________________________ Address: ___________________________________________________________________________________________ City: ______________________________________________ State: __________ Zip Code: ________________________ Account Number: ___________________________________ Origin date of Mortgage: ___________________________ What are your monthly payments? $__________________ What is the Payoff Amount: $__________________________ Are you behind on payments? Yes No If so which months: ___________________________________________ Amount needed to catch up payments? $____________________ Is this property in Foreclosure: Yes No What year was your mobile home last appraised? __________ What was the appraised value: _____________________ Do you have a 2nd Mortgage on the mobile home? YES No Please tell us your intent for the mobile home: Keep Surrender If in Collection, please provide a copy of the court documents you were served

SECOND MORTGAGE INFORMATION

Name of Mortgage Company: _________________________________________________________________________ Address: ___________________________________________________________________________________________ City: ______________________________________________ State: __________ Zip Code: ________________________ Account Number: ___________________________________ Origin date of Mortgage: ___________________________ What are your monthly payments? $__________________ What is the Payoff Amount: $__________________________ Are you behind on payments? Yes NO If so which months: ___________________________________________ Amount needed to catch up payments? $____________________ What year was your mobile home last appraised? __________ What was the appraised value: _____________________ Please tell us your intent for the property: Keep Surrender

COLLECTION INFORMATION (IF APPLICABLE)

Name of Collector or Attorney________________________________________________________________________ Address_______________________________ City___________________ State___________Zip code_______________

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HOUSEHOLD INVENTORY

Please check the items below that you currently have in your home. Then provide the YARD SALE VALUE of each item NOT the replacement value Yard Sale Value Stove/ Cooking Unit $____________ Painting/Art $___________ Refrigerator $____________ Describe item(s) _______________________________ Washer/Dryer $____________ _____________________________________________ Microwave $____________ Carpentry Tools $___________ Cooking Utensils $____________ Describe item(s) ________________________________ Silverware/ Flatware $____________ Mechanic Tools $____________ Living Room Furniture $____________ Describe Item(s) ________________________________ Guns and Firearms $____________ ____________________________________________ Dining Room Furniture $____________ Guns and Firearms $___________ Table and Chairs $____________ Describe Item(s) ________________________________ Television(s) $____________ ______________________________________________ VCR $____________ Lawn Mower $____________ DVD $____________ Boats $____________ Compact Disk(s) $____________ Trailers $____________ All other Stereo Equipment $____________ Camper $____________ Describe item(s) __________________________ Yard Tools / Equipment $____________ _________________________________________ Swimming Pool $____________ Bedroom Furniture $____________ Cell phones $____________ Dresser/Nightstands $____________ Computer(s) $____________ Lamps and Accessories $____________ Computer Printer(s) $____________ Wedding Rings $____________ Desk/ Office Furniture (personal use) $____________ Other Jewelry/ Watches $____________ Other Computer Equipment $____________ Describe: ______________________________ Describe: _______________________________________ ________________________________________ _____________________________________________ Photography Equipment $____________ Satellite Disks $____________ All Clothing $____________ Collectibles $____________ (include shoes, coats, hats, and etc.) Describe item(s): _________________________________ Furs $____________ _______________________________________________

OTHER ASSETS

Rent deposit with landlord (If you rent your residence). $____________ Name of Landlord___________________________________________________________________________________ Address____________________________________________________________________________________________ City_______________________________________ State __________________________ Zip code_________________ Government Bonds $____________ Certificate of Deposits $____________ Copyrights/ Patents $____________ Aircraft $____________ Interest in education IRA $____________ Other Items________________________ $____________ Other Items_______________ $____________ Other Items________________________ $____________ Other Items_______________ $____________ Other Items________________________ $____________

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YOUR MOTOR VEHICLES Motor Vehicles include: cars. Trucks, SUV’s. Motorcycles, mobiles homes, boats, trailers, campers and etc. that are TITLES IN YOU OR YOUR SPOUSE’S NAME. Please print additional sheets if you own, more than three vehicles Type: Automobile Truck Motorcycle Mobile Home (title only) Other: Year____________ Make ___________ Model___________ ______Style____________ 2dr 4dr Other Condition Excellence Good Fair Poor Not Running Mileage __________________________ Name(s) on title_____________________________________________________________________________________ Is vehicle leased YES NO If yes, what is the “buy out” on the lease? _____________________________________ Name of company you make the payments to for this vehicle: _______________________________________________ Address____________________________________________________________________________________________ City____________________________________ State __________________________ Zip code ____________________ Account Number_____________________________________ Date Established_________________________________ Monthly Payment $__________________________ How many months are you behind ___________________________ What is the pay off on this vehicle$______________________ Please check one: Keep Surrender Have you gone to a loan company and listed this vehicle as collateral for a persona loan or title loan? YES NO If so, Name of the company for title loan or personal loan: _________________________________________________ ________________________________________________________________ Amount of loan: $ __________________

Type: Automobile Truck Motorcycle Mobile Home (title only) Other: Year____________ Make ___________ Model___________ ______Style_____________ 2dr 4dr Other Condition Excellence Good Fair Poor Not Running Mileage _________________________ Name(s) on title_____________________________________________________________________________________ Is vehicle leased YES NO If yes, what is the “buy out” on the lease? _____________________________________ Name of company you make the payments to for this vehicle: ______________________________________________ Address____________________________________________________________________________________________ City____________________________________ State __________________________ Zip code ____________________ Account Number_____________________________________ Date Established_________________________________ Monthly Payment $__________________________ How many months are you behind ___________________________ What is the pay off on this vehicle$______________________ Please check one: Keep Surrender Have you gone to a loan company and listed this vehicle as collateral for a persona loan or title loan? YES NO If so, Name of the company for title loan or personal loan: _________________________________________________ ________________________________________________________________ Amount of loan: $ __________________ Type: Automobile Truck Motorcycle Mobile Home (title only) Other: Year____________ Make ___________ Model___________ ______Style_______________ 2dr 4dr Other Condition Excellence Good Fair Poor Not Running Mileage __________________________ Name(s) on title_____________________________________________________________________________________ Is vehicle leased YES NO If yes, what is the “buy out” on the lease? _____________________________________ Name of company you make the payments to for this vehicle: _______________________________________________ Address____________________________________________________________________________________________City____________________________________ State _______________________ Zip code _______________________ Account Number_____________________________________ Date Established________________________________ Monthly Payment $_________________ How many months are you behind _______________________________ What is the pay off on this vehicle$______________________ Please check one: Keep Surrender Have you gone to a loan company and listed this vehicle as collateral for a persona loan or title loan? YES NO If so, Name of the company for title loan or personal loan: _________________________________________________ ____________________________________________________________Amount of loan: $ ______________________

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DEBTOR INCOME INFORMATION DEBTOR 1

Your name as it is listed on your current paycheck stub: _____________________ ___________________________________________________________________ VERY IMPORTANT: Employer’s Name: ___________________________________ Address____________________________________________________________ City______________________ State____________ Zip code__________________ Telephone Number: __________________________________________________ Length of time at this job: _________________ Years ________Months ________ Job Title (do not abbreviate) __________________________________________ What are your wages before deductions? _________________________________ Do you receive overtime or commission?

Year to date Income: $_________________ Gross Income last year: $__________________ Gross Income 2 years ago: $___________________ $__________________ Amount of Overtime or commission $__________

How often do you get paid? -WEEKLY TWICE A MONTH (same 2 days of each month) -MONTHLY -EVERY 2 WEEKS (sometimes I get paid 3 times a month)

Do you pay Alimony or Child Support? Court Order YES NO $ __________________

Do you Pay Union Dues? $ __________________

How much social security do you receive per month? $ __________________

How much child support do you receive per month? $ __________________

How much retirement income do you receive per month? $ __________________

How much additional money do you earn per month? Do you have a 401K or retirement deduction? Account balance of 401 K or retirement savings Do you have other deductions form your paycheck? Do you have additional Income from a second job/ business/ flea market or etc? If so, please complete the following: Second Employer’s Name/ Business Name:______________________________ Address____________________________________________________________ City______________________ State____________ Zip code__________________ Telephone Number: __________________________________________________ Length of time at this job: _______________Years ___________Months _______ Job Title (do not abbreviate)___________________________________________ How often do you get paid: Weekly Monthly Bi-weekly Semi- monthly What are your wages before deductions? ________________________________ How much additional income do you make from a business, flea market, or etc? Monthly Income for real property (rentals) Monthly Income for Alimony/ Child Support received Monthly Government Assistance Monthly Public Assistance Monthly Dividends and Interest Monthly Social Security Monthly Food Stamps Monthly Pension

$ __________________ $ __________________ $ __________________ $ __________________ Year to date Income: $____________________ Gross Income last year: $______________________ Gross Income 2 years ago: $_______________________ $_______________________ $_______________________ $________________________ $________________________ $________________________ $________________________ $________________________ $________________________ $________________________ $_______________________

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DEBTOR INCOME INFORMATION DEBTOR 2 (SPOUSE)

Your name as it is listed on your current paycheck stub: _____________________ ___________________________________________________________________ VERY IMPORTANT: Employer’s Name: ___________________________________ Address____________________________________________________________ City______________________ State____________ Zip code__________________ Telephone Number: __________________________________________________ Length of time at this job: _________________ Years ________Months ________ Job Title (do not abbreviate) __________________________________________ What are your wages before deductions? _________________________________ Do you receive overtime or commission?

Year to date Income: $_________________ Gross Income last year: $__________________ Gross Income 2 years ago: $___________________ $__________________ Amount of Overtime or commission $_________

How often do you get paid? -WEEKLY TWICE A MONTH (same 2 days of each month) -MONTHLY -EVERY 2 WEEKS (sometimes I get paid 3 times a month)

Do you pay Alimony or Child Support? Court Order YES NO $ __________________

Do you Pay Union Dues? $ __________________

How much social security do you receive per month? $ __________________

How much child support do you receive per month? $ __________________

How much retirement income do you receive per month? $ __________________

How much additional money do you earn per month? Do you have a 401K or retirement deduction? Account balance of 401 K or retirement savings Do you have other deductions form your paycheck? Do you have additional Income from a second job/ business/ flea market or etc.? If so, please complete the following: Second Employer’s Name/ Business Name:______________________________ Address____________________________________________________________ City______________________ State____________ Zip code__________________ Telephone Number: __________________________________________________ Length of time at this job: _______________Years ___________Months _______ Job Title (do not abbreviate)___________________________________________ How often do you get paid: Weekly Monthly Bi-weekly Semi- monthly What are your wages before deductions? ________________________________ How much additional income do you make from a business, flea market, or etc.? Monthly Income for real property (rentals) Monthly Income for Alimony/ Child Support received Monthly Government Assistance Monthly Public Assistance Monthly Dividends and Interest Monthly Social Security Monthly Food Stamps Monthly Pension

$ __________________ $ __________________ $ __________________ $ __________________ Year to date Income: $____________________ Gross Income last year: $______________________ Gross Income 2 years ago: $_______________________ $_______________________ $_______________________ $________________________ $________________________ $________________________ $________________________ $________________________ $________________________ $________________________ $________________________

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BUSINESS OWNERS

If you have been self-employed the past 12 months, please list below the normal income and expenses your business generates for an average month. If you did not have an average monthly income due to extreme highs and lows in your business, estimate you total yearly income and divide it by 12 to get the average monthly income. Use the same methods to determine your average monthly expenses and enter those figures in to the spaces below. Average monthly business income $_________________________________ Did you withhold any earnings for tax purposes YES NO If yes How much did you withhold monthly? $_________________________________ Average monthly business expenses (if applicable) Rent and Utilities $_________________________________ Office Supplies $_________________________________ Product Supplies $_________________________________ Wages $_________________________________ Equipment Leases $_________________________________ Other Business Leases $_________________________________ Other__________________________________________ $_________________________________ Other__________________________________________ $_________________________________ Other__________________________________________ $_________________________________ Other__________________________________________ $_________________________________ Other__________________________________________ $_________________________________ Other__________________________________________ $_________________________________ Other__________________________________________ $_________________________________ Other__________________________________________ $_________________________________ Total Average Monthly Income $_________________________________ Total Average Monthly Expenses $_________________________________ Total Average Monthly Business Profit $_________________________________ Did you file income taxes for the years you operated your business YES NO If not, what years did you NOT file taxes____________________________

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MONTHLY LIVING EXPENSES Please provide an AVERAGE amount that your household pays PER MONTH for the following expenses.

Rent Payment (if you do not own your home)

$ Charitable Giving (if claimed on taxes) $

First Mortgage payment or Mobile Home Payment

$ Past Due Taxes deductions Type of tax payment: _______________

$

Second Mortgage Payment $ Cell Phone Bill $

Third Mortgage $ Cell phone value $

Lot Payment $ Home Phone $

Are taxes real estate taxes included in the mortgage payment

YES NO Alimony or Child Support $

Real Estate Tax Amount not included in house payment

$ Union Dues $

Is your home insurance included in your mortgage payment?

YES NO Professional Dues $

Insurance not included in house payment $ School Lunch Expenses $

Monthly Home Maintenance $ School Expenses $

Electricity $ Lawn Maintenance $

Gas $ Pool Maintenance $

Water and sewer $ New paper, Books and Magazines $

Garbage Pick-Up $ Personal Care Items $

Cable T.V. $ Uniforms $

Food (Monthly) $ Motor Vehicle Payment #1 $

Clothing (Monthly) $ Motor Vehicle Payment #2 $

Laundry, dry cleaning, soap, etc. $ Payments for someone outside of your home $

Medical Expenses (not paid by insurance) $ Student Loan Repayment $

Life Insurance (other than employer) $ Tuition Payments (not Loans) $

Health Insurance $ Furniture Payment $

Renters Insurance $ Jewelry Payments $

Auto Insurance $ Boat and RV $

Other Insurance $ Child Care $

Gasoline for Motor Vehicles $ Infant Expenses $

Recreation $ Payments to family member $

Please use the space below to describe any additional monthly expenses that you must pay out of your pocket that are not covered her. Explain the type of expense, amount of expense, and how long you will continue to this expense: ____________________________________________________________________________________________________________________________________________________________________________________________________

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STATEMENT OF AFFAIRS (1 of 11) The following pages contain extremely IMPORTANT QUESTIONS. Please take your time and review every question and provide as much information as possible to any question you answer “YES “to. List the names of all spouse(s) past or present that you have been married to, as well as the dates you were married to this spouse: Full Name (First, Middle, Last): _______________________________________________________________________ Dates Married: From: ____________________________ To: _______________________________________ Full Name (First, Middle, Last):_________________________________________________________________________ Dates Married: From: ____________________________ To: _______________________________________ Full Name (First, Middle, Last):_________________________________________________________________________ Dates Married: From: ____________________________ To: _______________________________________ Full Name (First, Middle, Last):_________________________________________________________________________ Dates Married: From: ____________________________ To: _______________________________________ Have you ever provided a notice to any governmental unit of a Release of Hazardous Materials? YES NO If so, list the name and address of every site for which you provided notice to a governmental unit of release of Hazardous Material. Indicate the governmental unit to which the notice was sent and the date of the notice. Name/ Address of Site _______________________________________________________________________________ Governmental Unit Notice Sent to ______________________________________________________________________ Date Notice Sent to Governmental Unit__________________________________________________________________ Do you share ownership of any real property with another person such as co-tenancy or joint tenancy? This does not apply to your spouse. YES NO Name of Person________________________________________ Do you have future interest in any real estate, such as putting money down on property you have not purchased? YES NO Details_______________________________________________________ Do you own or are you buying a time share in a vacation property or resort? YES NO Details______________________________________________________ Do you have a car, truck, motorcycle, boat, camper in your possession titled in someone else’s name? YES NO Year, Make, Model of Vehicle_________________________________________________________________________ Whose name is the motor vehicle titled to? ______________________________________________________________ Address____________________________________________________________________________________________ City___________________________________________ State______________________________ Zip__________________ What is the relationship to you? ______________________________________________________________________ Why are you holding this property? ____________________________________________________________________

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STATEMENT OF AFFAIRS (2 of 11) Are you buying any of your furniture or appliances with installment payments? YES NO Description of Item(s) 1.___________________________________________________________ Yard Sale Value____________________ 2. ___________________________________________________________ Yard Sale Value____________________ 3. ___________________________________________________________ Yard Sale Value ____________________ Name of Company you make installment payments to: _____________________________________________________

• MAKE SURE YOU LIST THEM ON THE DEBT SHEETS Are you renting –to own any of your furniture or appliances? YES NO Description of Item(s) 1.___________________________________________________________ Yard Sale Value___________________ 2. ___________________________________________________________ Yard Sale Value___________________ 3. ___________________________________________________________ Yard Sale Value ___________________ Name of Company you make installment payments to: _____________________________________________________

• MAKE SURE YOU LIST THEM ON THE DEBT SHEETS Have you gone to a loan company or bank and listed any of your furniture appliances or personal possessions at the time you obtained the loan? YES NO Description of Item(s) 1.___________________________________________________________ Yard Sale Value___________________ 2. ___________________________________________________________ Yard Sale Value___________________ 3. ___________________________________________________________ Yard Sale Value ___________________ Name of Company you make installment payments to: _____________________________________________________

• MAKE SURE YOU LIST THEM ON THE DEBT SHEETS Do you own or are you buying any tools or equipment that you use for your work? YES NO Description of Item(s): ______________________________________________________________________________ Value of the items if sold at a flea market or yard sale: ______________________________________________________ If making payments on the item what is the name of the company? ___________________________________________

• MAKE SURE YOU LIST THEM ON THE DEBT SHEETS At present do you have any inventory (stock in trade) that could be sold for more than $200 YES NO Description of Item(s): _______________________________________________________________________________ Value of Item if sold at a flea market or yard sale: __________________________________________________________

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STATEMENT OF AFFAIRS (3 of 11)

Are you buying jewelry with installment payment? YES NO Description of Item(s) 1.___________________________________________________________ Yard Sale Value___________________ 2. ___________________________________________________________ Yard Sale Value___________________ 3. ___________________________________________________________ Yard Sale Value ___________________ Name of Company you make installment payments to: _____________________________________________________

• MAKE SURE YOU LIST THEM ON THE DEBT SHEETS Do you have any animals, livestock, or pets you could sell for $200 or more? YES NO Description of Animal(s) ______________________________________________________________________________ Value of animal if you had to sell them __________________________________________________________________ Do you have any checking or saving account(s) at this time? YES NO Name of Bank ______________________________________________________________________________________ Address of Branch___________________________________________________________________________________ City____________________________________ State__________________________ Zip code_____________________ Type of account: Checking Saving or Both Name on the Account________________________________________________________________________________ Account Number Checking_______________________________________ Present Balance________________________ Account Number Savings_______________________________________ Present Balance________________________ Name of Second Bank (if applicable) ____________________________________________________________________ Name of Bank ______________________________________________________________________________________ Address of Branch___________________________________________________________________________________ City____________________________________ State__________________________ Zip code_____________________ Type of account: Checking Saving or Both Name on the Account________________________________________________________________________________ Account Number Checking___________________________________ Present Balance____________________________ Account Number Savings___________________________________ Present Balance____________________________ Have you closed any bank accounts within the past two (2) years? YES NO Name of Bank _____________________________________________________________________________________ Address of Branch___________________________________________________________________________________ City____________________________________ State__________________________ Zip code_____________________ Type of account: Checking Saving or Both Name on the Account________________________________________________________________________________ Account Number Checking__________________________________ Date closed________________________________ Did you owe a balance when you closed this account? YES NO Balance owed ______________ If you did not owe a balance when you closed this account, how much did you receive? _______________________

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STATEMENT OF AFFAIRS (4 of 11) Do you or have you a rented safe deposit box during the past two (2) years? YES NO Name of Financial Institution___________________________________________________________________________ Address of Financial Institution_________________________________________________________________________ City________________________________ State ___________________________ Zip____________________________ What are the contents of the safe deposit box? ___________________________________________________________ __________________________________________________________________________________________________ What monthly amount do you pay for rental of this deposit box _____________________________________________? If you no longer have the safe deposit box, what date/year did you surrender it? ________________________________ If you transfer the safe deposit box, who did you transfer it to? ______________________________________________ Do you have a Christmas club account or any special purpose accounts? YES NO Name of Financial Institution__________________________________________________________________________ Address ___________________________________________________________________________________________ City____________________________________ State__________________________ Zip code_____________________ Type of account: Checking Saving Both Name on the Account________________________________________________________________________________ Account Number __________________________________________ Present Balance____________________________ Do you have any security deposits being held by a utility company? YES NO If yes, what is the amount? ________________________________Name of Utility company _______________________ City_____________________________________ State_______________________________ Zip___________________ Account Number________________________________________ Present Balance______________________________ ** Remember to include any past –due utility bills that you owe from previous addresses on your Debt Sheets. Do you Have Life Insurance? YES NO If you have a “Whole Life “Policy—what is the current cash value? ____________________________________________ If your life insurance is only payable upon death, what is the face value of the policy? ____________________________ Who is the beneficiary? ________________________________________________ Relationship____________________ ***If you have other Life insurance policies, please list the information above for each. __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Do you or your spouse participate in a retirement, 401K, or pension plan? YES NO Type of pension plan (i.e... 401-K PERS. etc.) ______________________________________________________________ When did you first enroll in this plan? _____________________________________Current Cash Value______________

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STATEMENT OF AFFAIRS (5 of 11) Have you set up your own separate retirement account not provides by your employer? YES NO Name of Financial Institution (if applicable) _______________________________________________________________ Amount in this separate retirement account? ______________________Who is the beneficiary? ___________________ Will you be receiving benefits from a previous employer within the next six (6) months YES NO Date you expect to start receiving benefits_______________________________________________________________ Do you have any stocks bonds (including savings bonds) or mutual funds? YES NO Type of bond, stock, mutual fund: ______________________________________________________________________ Does this bond, stock, or mutual fund have a cash value? YES NO Cash Value: ________________________ Do you have a cell phone? YES NO Name of cell phone company__________________________________________________________________________ Address____________________________________________________________________________________________ City _______________________________________________State ____________________________Zip____________ Account Number_____________________________________ Date the contract began___________________________ Is this a month to month YES NO? If not, what is the length of the contract? 1 year 2 year 3 year Other What is your monthly contract payment? (i.e... $ 19.95, $29.95, etc.) _________________________________________ Do you wish to keep the cell phone and continue paying the monthly contract? YES NO If you have more than one cell phone, please list the information below________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ Do you live with a roommate/relative that pays part of your expense? YES NO Name of roommate or relative: _________________________________________ Relationship_________________________ What expenses do they pay? _________________________________________________________________________ __________________________________________________________________________________________________ What is the total amount they contribute on a monthly basis to your living expenses? YES NO How long have they been paying this amount? From ______________________ to _______________________ Do you relatives or other parties help to pay part or all of your monthly expenses? YES NO Name of relatives providing additional support: ___________________________________________________________ Relationship of this relative____________________________________________________________________________ What is the total amount they contribute on a monthly basis to your living expense? __________________________ What how long have they been paying this amount? From ______________________ to _______________________

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STATEMENT OF AFFAIRS (6 of 11) Are you currently attending college? YES NO Name of college_____________________________________________________________________________________ Anticipated graduation date___________________________________________________________________________ Do you have a student loan? Name of institution you will make payments to: ___________________________________________________________ Address____________________________________________________________________________________________ City_______________________________________________State________________________________Zip_________ Date student loan obtained? ___________________________ Date payment is/was to begin______________________ Total amount to pay off student loan __________________________Average monthly payment___________________ Do you currently owe any fines? (Including parking tickets, moving violations, etc.) YES NO Name of court you owe fines to________________________________________________________________________ Address ___________________________________________________________________________________________ City _______________________________________ State ________________________________ Zip _______________ Date of occurrence ______________________________________________ Amount owed________________________ Case number assigned by the courts________________________________ Name of party Husband Wife Other What was the fine for? _______________________________________________________________________________ If you pay child support, are you currently behind any payments? YES NO Name of person/agency you pay child support to __________________________________________________________ Address ___________________________________________________________________________________________ City _______________________________________ State __________________ Zip _____________________________ What is the total amount you are owed in back child support? _______________________________________________ What date (or year) were you suppose to start paying child support? __________________________________________ If, so what are the payment amounts? ______________________ How often? __________________________________ Even if you never expect to collect any money, does an ex- spouse owe you money for alimony or child support? YES NO Name of Ex-Spouse_________________________________________________________________________________ Address of Ex-Spouse_________________________________________________________________________________ City_______________________________________State________________________ Zip ________________________ Total amount he/she owes you _______________________ Date originally started owing you______________________ Has this ex-spouse been court ordered to pay you? __________________Year of Court order______________________ Over the last year, have you, your children or your spouse been involved in an accident where someone was hurt, for example a car accident? YES NO Date accident occurred _____________________ Who was at fault? _________________________________________ Who was involved in the accident? _____________________________________________________________________ Was any insurance money received? YES NO If yes, how much_______________________________________ During the next six (6) months, do you expect to inherit anything? YES NO How much do you expect to inherit? ___________________________ Date expected_____________________________ Reason for inheritance___________________________________________________________________________________

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STATEMENT OF AFFAIRS (7 of 11) During the next six (6) months do you expect to recover on anyone’s life insurance policy? YES NO How much do you expect to receive? _________________________________ Date expected ______________________ Reasons for receiving this money_______________________________________________________________________ During the next six (6) months do you expect to receive any money from an insurance claim for any reason? YES NO How much do you expect to receive? _________________________________ Date expected ______________________ Reasons for receiving this money_______________________________________________________________________ Are you the beneficiary of a trust fund? YES NO What is the amount of the trust fund? ___________________ Name of trust fund owner__________________________ Relationship to you____________________________ When will you have access to this trust fund__________________ Are you owed any back wages, commissions, or vacation pay from your current or previous employer? YES NO Employer Name______________________________________________________________ _______________________ Reasons for receiving this money________________________________________ Date expected ________________

• Please provide details about this amount owed. ** __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Is any of your property in the hands of a repairman, storage, company or pawnbroker? YES NO Name of Place Holding Your Property_______________________________________________________________________ Address____________________________________________________________________________________________ City__________________________________________State_____________________ Zip_________________________ Description of items and yard sale value: 1. _____________________________________________________ Yard Sale Value_____________________________ 2. _____________________________________________________ Yard Sale Value_____________________________ 3. _____________________________________________________ Yard Sale Value_____________________________ 4. _____________________________________________________ Yard Sale Value_____________________________ 5. _____________________________________________________ Yard Sale Value_____________________________ What is the total amount you need to pay in order to get these items released ________________________________? In the future do you expect to enter settle, win or begin a case for personal injury? YES NO How much do you expect to receive? _______________________ Date you expect to receive this money? ___________ Provide details about this personal injury claim___________________________________________________________ __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Name of attorney or law firm handling this claim? ____________________________________________________________________________________________________________________________________________________________________________________________________

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STATEMENT OF AFFAIRS (8 of 11)

In the future do you expect to enter into any property settlement? YES NO List all items you expect to receive or turn over in the property settlement ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ __________________________________________________________________________________________________ What is the total market value (yard dale value) of these items? _____________________________________________ When do you expect to receive this money or property? __________________________________________________ When do you expect to turn it over? ___________________________________________________________________ Does anyone you owe money for a judgment you obtained against them? ____________________________________ Name of party you filed a law suit on ____________________________________________________________________ Address____________________________________________________________________________________________ City ___________________________________ State _______________________________________Zip____________ Date you filed the law suit___________________________ Money awarded to you ______________________________ Even if you never collect it, does anyone owe you money for any reason right now? YES NO Name of person that owes you money_______________________________________________________________________ Address____________________________________________________________________________________________ City ___________________________________ State _______________________________________Zip____________ Explain why they owe you____________________________________________________________________________ ____________________________________________________________________________________________________________________________________________________________________________________________________ Amount they owe you? __________________________ date they started owing you?____________________________ Have you made any payments on your loans or bills other than ordinary payments? In other words, have you made catch-up payments, paid off or borrowed on or off bills or loans? YES NO 1. Name of Creditor You Paid________________________________ Last four numbers of the account_______________ Date Paid ________________ Amount paid____________________ Current Balance Due _______________________ 2. Name of Creditor You Paid________________________________ Last four numbers of the account_______________ Date Paid ________________ Amount paid_____________________ Current Balance Due _______________________ 3. Name of Creditor You Paid________________________________ Last four numbers of the account_______________ Date Paid ________________ Amount paid_____________________ Current Balance Due _______________________ 4. Name of Creditor You Paid________________________________ Last four numbers of the account_______________ Date Paid ________________ Amount paid_____________________ Current Balance Due _______________________

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STATEMENT OF AFFAIRS (9 of 11) Are there any lawsuits pending against you now? YES NO Name of party suing you (Plaintiff) ____________________________________________________________________ Case Number ___________________________________________ Date Lawsuit Filed____________________________ Type of Lawsuit from Court Pleading (Complaint, Summons, etc.) _____________________________________________ Attorney for the Plaintiff (found on court pleading): _______________________________________________________ Address____________________________________________________________________________________________ City___________________________________ State ______________________________ Zip______________________ Court where lawsuit was filed (at the top of pleading) Address____________________________________________________________________________________________ City___________________________________ State ______________________________ Zip______________________

• If lawsuit is less than 1 YEAR OLD, please make a copy and include with these forms* Have your wages or property been garnished or attached (repossessed)? YES NO Who garnished your wages or attached your property? _____________________________________________________ What item did they repossess (if car please provide year, make and model). ____________________________________ __________________________________________________________________________________________________ How much money did they take from your paycheck? ___________________How often is this deducted? ___________ ____________________________________________________________________________________________________________________________________________________________________________________________________ Have you returned any property to creditors or was any of your property repossessed from you, sold at foreclosure, transferred through a deed, or returned to a seller? YES NO What property did you turn over to a receiver? __________________________________________________________ When and where did this take place? ___________________________________________________________________ Is any of your property in receivership or other legal custody? ______________________________________________ When did you file your receivership? ____________________________________________________________________ In what court was this done? __________________________________________________________________________ Have you made any gifts to friends or relatives? YES NO What gifts or transfers have you made? _________________________________________________________________ Who did you give the gift to? _________________________________________________________________________ What date/ year did you make the gift?) ____________ What is the approximate value? __________________________ Have you transferred any money or property to family member or friends, or paid them any money on debts you might owe them? YES NO Type of property transferred: __________________________________________________________________________ What date /year was it transferred_____________________________ What is the approximate value? _____________ Have you any unusual losses, such as fire, theft, gambling, or otherwise? YES NO Type of Loss: Fire Theft Gambling Other: ____________________________________________ What item(s) or amount of money was lost? ______________________________________________________________ What date /year was it lost? ___________________ Amount insurance paid? __________________________________ Have you had any losses covered by insurance? YES NO Describe loss: ____________________________________________________________________________________ Date/ year of loss? __________________________ Amount insurance paid__________________________________

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STATEMENT OF AFFAIRS (10 of 11)

Have you consulted with an attorney about your financial affairs or paid money to a debt counseling service?

YES NO Name of Attorney or service_________________________________________________________________________ Address___________________________________________________________________________________________ City___________________________________ State _____________________________ Zip code __________________ Consultation Date_________________________ Amount paid for service ______________________________________ Have you filed bankruptcy within the last eight (8) years? YES NO Did you file: Chapter 7 Chapter 13 Chapter 11 Date your bankruptcy was filed? ______________ City/ State Where Filed? _____________________________________ Name of person who filed? ____________________________________________________________________________ Was the case discharged? YES NO Case Number__________________________________________ Is anyone holding property that belongs to you? YES NO Items(s) in someone else’s possession that belong to you? __________________________________________________ ____________________________________________________________________________________________________________________________________________________________________________________________________ Name of person holding these items(s): ________________________________________________________________ Address____________________________________________________________________________________________ City ______________________________________ State ___________________________ Zip _____________________ Have you lived at any other address within the past six (6) months (do not include your current address). YES NO Previous Address: ___________________________________________________________________________________ City _________________________________________State ___________________ Zip code______________________ Time period lived at this address: From (date/year) ___________________________ to (date/year) _________________ Name (s) of parties who lived at this address: _____________________________________________________________ __________________________________________________________________________________________________ Previous Address: ___________________________________________________________________________________ City _________________________________________State ______________________ Zip code ___________________ Time period lived at this address: From (date/year) ___________________________ to (date/year) ________________ Name (s) of parties who lived at this address __________________________________________________________ __________________________________________________________________________________________________ Have you been self- employed or had any financial interest in any business (or been involved in a partnership with someone who owned a business within the past eight (8) years? YES NO Name of business ___________________________________________________________________________________ Business address ____________________________________________________________________________________ Type of business ____________________________________________________________________________________ Date business began ________________________________Date business ended _______________________________ Name of your partners, co –investors, or associates? ______________________________________________________ How much income tax do you pay from the income you make with your business? _______________________________

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STATEMENT OF AFFAIRS (11 of 11)

During the past two years, have either you or your spouse had any other income source outside of the normal pay from your employer? (Please include flea market dealers). YES NO Income this year: ________________________ Last year ___________________ 2 years ago ____________________ What is the amount of TAX REFUND you received this year? ____________________________________________________

I did not file taxes I have to pay taxes and did not get a refund

STATEMENT OF ACCURACY

By signing my/our names below, I/we state that the information in this Initial Intake Form is true and correct to the best of my/our knowledge. Spouse #1 Signature Date Spouse #1 Signature Date

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Listed below is the Bankruptcy Document Checklist. We will need these documents to complete your bankruptcy in a timely manner. Please provide us with this information as soon as you possibly can.

CHAPTER 7 BANKRUPTCY DOCUMENT CHECKLIST: ______ Certificate of credit counseling. ______ Six (6) months of recent paycheck stubs from debtor(s). ______ Documents showing income from sources other than employment for six (6) months. ______ Federal tax returns two (2) years and W2’s and/or 1099’s showing Income for previous two years. ______ Bank statements for last three (3) months. ______ Separation agreements or decrees of dissolution or divorce within past one (1) year. _______ Copies of any lawsuits filed within the past two (2) years. _______ Billing Statements evidencing money owed to you. _______ Copies of all Summonses, Complaints or other Court documents served upon debtor(s). _______ Verification of debtor’s disabled veteran status for debtor asserting qualification for the disabled veteran safe harbor from means testing pursuant to § 707(b)(2)(D).