STATEMENT OF FINANCIAL AFFAIRS
BUSINESS DEBTOR
United States Bankruptcy Court
District of _______________________________
In re _______________________,
Case No. ____________________
STATEMENT
OF FINANCIAL AFFAIRS
This statement is to be completed by every
debtor. Spouses filing a joint petition
may file a single statement on which the information for both spouses is
combined. If the case is filed under
Chapter 13, a married debtor must furnish information for both spouses whether
or not a joint petition is filed, unless the spouses are separated and a joint
petition is not filed. An individual
debtor engaged in business as a sole proprietor, partner, family farmer, or
self-employed professional, should provide the information requested on this
statement concerning all such activities as well as the individuals personal
affairs.
Questions 1-15 are to be completed by all
debtors. Debtors that are or have been
in business, as defined below, also must complete Questions 16-21. Each question must be answered. If the answer to any question is None, or
the question is not applicable, mark the box labeled None. If additional space if needed for the answer
to any question, use and attach a separate sheet properly identified with the
case name, case number (if known), and the number of the question.
Definitions
In business.
A debtor is in business for the purpose of this form if the debtor is a
corporation or partnership. An
individual debtor is in business for the purpose of this form if the debtor is
or has been, within the past two years immediately preceding the filing of this
bankruptcy case, any of the following: an officer, director, managing
executive, or person in control of a corporation; a partner, other than a
limited partner, of a partnership; a sole proprietor or self-employed.
Insider. The
term insider includes but is not limited to: relatives of the debtor; general
partners of the debtor and their relatives; corporations of which the debtor is
an officer, director, or person in control; officers, directors, and any person
in control of a corporate debtor and their relatives; affiliates of the debtor
and insiders of such affiliates; any managing agent of the debtor. 11 U.S.C. sec.101(30).
1. Income
from the employment or operation of business
None _____________
State the gross amount of income the debtor has
received from employment, trade, or profession, or from operation of the
debtor’s business form the beginning of this calendar year to the date this
case was commenced. State also the
gross amounts received during the two years immediately preceding this calendar
year. (A debtor that maintains, or has
maintained, financial records on the basis of a fiscal rather than a calendar
year may report fiscal year income.
Identify the beginning and ending dates of the debtors fiscal
year.) If a joint petition is filed,
state income for each spouse separately.
(Married debtors filing under Chapter 12 or Chapter 13 must state income
of both spouses whether or not a joint petition is filed, unless the spouses
are separated and a joint petition is not filed.)
Amount and Source (If more than one)
_____________________________________
2. Income
from other than employment or operation of business
None __________
State the amount of income received by the debtor
other than from employment, trade, profession, or operation of the debtor’s
business during the two years immediately preceding the commencement of this
case. Give particulars. If a joint petition is filed, state income
for each spouse separately (Married debtors filing under Chapter 12 or Chapter
13 must state income for each spouse whether or not a joint petition is filed,
unless the spouses are separated and a joint petition is not filed.)
Amount and
Source: __________________________________________________
3. Payments to creditors
a. Kist all
payments on loans, installment purchases of goods or services, and other debts,
aggregating more than $600 to any creditor, made within 90 days immediately
preceding the commencement of this case. (Married debtors filing under Chapter
12 or Chapter 13 must state income of both spouses whether or not a joint
petition is filed, unless the spouses are separated and a joint petition is not
filed.)
Name and address of Creditor:
____________________________________________
Dates of Payments:
_____________________________________________________
Amount Paid and Amount Still Owing _______________________________________
None _________
b. List all payments on loans made within one year
immediately preceding the commencement of this case, to or for the benefit of,
creditors ware or were insiders. (Married debtors filing under Chapter 12 or
Chapter 13 must state income of both spouses whether or not a joint petition is
filed, unless the spouses are separated and a joint petition is not filed.)
(Married debtors filing under Chapter 12 or Chapter 13 must state income of
both spouses whether or not a joint petition is filed, unless the spouses are
separated and a joint petition is not filed.)
Name and Address of Owing Creditor; related to
Debtor: ________________________
____________________________________________________________________
Dates of Payments:
_____________________________________________________
Amount Paid and Amount Still Owing:
______________________________________
___________________________________________________________________
4. Suits,
executions, garnishments and attachments:
None ___________
a. List all suits to which the debtor is or was a
party within one year immediately preceding the filing of this bankruptcy case.
(Married debtors filing under Chapter 12 or Chapter 13 must state income of
both spouses whether or not a joint petition is filed, unless the spouses are
separated and a joint petition is not filed.)
Caption of Suit and Case number:
__________________________________________
Nature of Proceeding Court and Location:
____________________________________
Status or Disposition:
___________________________________________________
None _________
b. Describe
all property that has been attached, garnished, or seized under any legal or
equitable process within one year immediately preceding the commencement of
this case. (Married debtors filing under Chapter 12 or Chapter 13 must state
income of both spouses whether or not a joint petition is filed, unless the
spouses are separated and a joint petition is not filed.)
Name and Address of Person for whose benefit
property was seized: ______________
___________________________________________________________________
Date of Seizure:
_______________________________________________________
Description and Value Property:
___________________________________________
____________________________________________________________________
5. Repossessions, foreclosures, and returns
None ________
List all property that has been repossessed by a
creditor, sold at a foreclosure sale, transferred through a deed in lieu of
foreclosure or returned to the seller, within one year immediately preceding
the commencement of this case. (Married debtors filing under Chapter 12 or
Chapter 13 must state income of both spouses whether or not a joint petition is
filed, unless the spouses are separated and a joint petition is not filed.)
Name and Address of Credit or Seller :
______________________________________
____________________________________________________________________
Date of Repossession, foreclosure or return:
__________________________________
_____________________________________________________________________
6.
Assignments and Receiverships
None ____________
a. Describe
any assignment of property for the benefit of creditors made within 120 days
immediately preceding the commencement of this case. (Married debtors filing
under Chapter 12 or Chapter 13 must state income of both spouses whether or not
a joint petition is filed, unless the spouses are separated and a joint
petition is not filed.)
Name and Address of Assignee:
__________________________________________
___________________________________________________________________
Date of Assignment:
___________________________________________________
Terms of Assignment or Settlement:
_________________________________________
____________________________________________________________________
None __________
b. List all property which has been in the hands of
a custodian, receiver, or court-appointed official within one year immediately
preceding the commencement of this case. (Married debtors filing under Chapter
12 or Chapter 13 must state income of both spouses whether or not a joint
petition is filed, unless the spouses are separated and a joint petition is not
filed.) (Married debtors filing under Chapter 12 or Chapter 13 must state
income of both spouses whether or not a joint petition is filed, unless the
spouses are separated and a joint petition is not filed.)
Name and Address of custodian: ___________________________________________
____________________________________________________________________
Name and Location of court case title and number:
_____________________________
____________________________________________________________________
Date of Order:
_________________________________________________________
Description and Value of Property:
_________________________________________
____________________________________________________________________
7. Gifts
None ________
List all gifts or charitable contributions made
within one year immediately preceding the commencement of this case except
ordinary and usual gifts to family members aggregating less than $200 in value
per individual family member and charitable contributions aggregating less than
$100 per recipient. (Married debtors filing under Chapter 12 or Chapter 13 must
state income of both spouses whether or not a joint petition is filed, unless
the spouses are separated and a joint petition is not filed.)
Name and Address of Person and Organization:
_______________________________
____________________________________________________________________
Relationship to Debtors:
__________________________________________________
_____________________________________________________________________
Date of Gift:
___________________________________________________________
_____________________________________________________________________
Description and Value of Gift:
_____________________________________________
_____________________________________________________________________
8. Losses
None ________
List all losses from fire, theft, other casualty, or
gambling within one year immediately preceding the commencement of this case or
since the commencement of this case. (Married debtors filing under Chapter 12
or Chapter 13 must state income of both spouses whether or not a joint petition
is filed, unless the spouses are separated and a joint petition is not filed.)
Description and Value Of Property:
_______________________________________
Description of Circumstances and, if loss was
Covered in Whole or in Part by Insurance Give Particulars:
_______________________________________________________
____________________________________________________________________
Date of Loss
___________________________________________________________
_____________________________________________________________________
9. Payments
related to debt counseling or bankruptcy
None ________
List all payments made or property transferred by or
on behalf of the debtor to any person, including attorneys, for consultation
concerning debt consolidation, relief under the bankruptcy law or preparation
of a petition in bankruptcy within one year immediately preceding the
commencement of this case.
Name and Address of Payee:
___________________________________________
__________________________________________________________________
Date of Payment; and Name of Payor if other than
Debtor: _____________________
___________________________________________________________________
Amount of Money or Description and Value of
Property: ________________________
____________________________________________________________________
10. Other transfers
None ________
a. List all
other property, other than property transferred in the ordinary course of the
business or financial affairs of the debtor, transferred wither absolutely or
as a security within one year immediately preceding the commencement of this
case. (Married debtors filing under Chapter 12 or Chapter 13 must state income
of both spouses whether or not a joint petition is filed, unless the spouses
are separated and a joint petition is not filed.)
Name and Address of Transferee; Relations to Debtor:
_________________________
Date and Describe Property Transferred and Value
Received: ____________________
___________________________________________________________________
11. Closed financial accounts
None
________
List all financial accounts and instruments held in
the name of the debtor or for the benefit of the debtor which were closed,
sold, or otherwise transferred within one year immediately preceding the
commencement of this case. Include
checking, savings, and other financial accounts, certificates of deposit, or
other instruments; shares and share accounts held in banks, credit unions,
pension funds, cooperatives, associations, brokerage houses, and other
financial institutions. (Married debtors filing under Chapter 12 or Chapter 13
must state income of both spouses whether or not a joint petition is filed,
unless the spouses are separated and a joint petition is not filed.)
Name and Address of Institution:
__________________________________________
____________________________________________________________________
Type and Number of Account and Amount in Financial Balance __________________
___________________________________________________________________
Amount and of Sale or Closing: ____________________________________________
_____________________________________________________________________
12. Safe
deposit boxes
None ________
List each safe deposit or other box or depository in
which the debtor has or had securities, cash, or other valuables within one
year immediately preceding the commencement of this case. (Married debtors
filing under Chapter 12 or Chapter 13 must state income of both spouses whether
or not a joint petition is filed, unless the spouses are separated and a joint
petition is not filed.)
Name and Address of Bank or Depository:
__________________________________
___________________________________________________________________
Names and Addresses of those with access to box or
Depository: _________________
___________________________________________________________________
Description of Contents:
_________________________________________________
____________________________________________________________________
13. Setoffs
None ________
List all setoffs made by any creditor, including a
bank, against a debt or deposit of the debtor within 90 days preceding the
commencement of this case. (Married debtors filing under Chapter 12 or Chapter
13 must state income of both spouses whether or not a joint petition is filed,
unless the spouses are separated and a joint petition is not filed.)
Name and Address of Creditor:
__________________________________________
__________________________________________________________________
Date of Setoff; ______________________________________________________
__________________________________________________________________
Amount of Set of:
_____________________________________________________
14. Property held for other person
None _________
List all Property owned by another person that the
debtor holds or controls.
Name and Address of Property Owner:
_____________________________________
___________________________________________________________________
Description and Value of Property:
________________________________________
___________________________________________________________________
Location of Property:
________________________________________________
______________________________________________________________________
15. Prior
address of debtor
None ________
If the debtor has moved within the two years
immediately preceding the commencement of this case, list all premises which
the debtor occupied during that period and vacated prior to the commencement of
this case. If a joint petition is filed,
report also any separate address of wither spouse.
Address:
____________________________________________________________
Name Used:
_________________________________________________________
Dates of Occupancy:
___________________________________________________
The following questions are to be completed by every
debtor that is a corporation or partnership and by any individual debtor who is
or has been, with the two years immediately preceding the commencement of this
case, any of the following: an officer, director, managing, executive, or owner
of more than 5 percent of the voting
securities of a corporation; a partner, other than a limited partner, of a
partnership; a sole proprietor or otherwise self-employed.
( An individual or joint
debtor should complete this portion of the statement only if the debtor is or
has been in business, as defined above, within the two years immediately
preceding the commencement of this case.)
16. Nature, location, and name of business.
None ________
a. If the debtor
is an individual, list the names and addresses of all businesses in which the
debtor was an officer, director, partner, or managing executive of a
corporation, partnership, sole proprietorship, or was a self-employed
professional within the two years immediately preceding the commencement of
this case, or in which the debtor owned 5 percent or more of the voting or
equity securities within the two years immediately preceding the commencement
of this case.
b. If the
debtor is a partnership. List the names and addresses of all businesses in
which the debtor was a partner or owned 5 percent or more of the voting
securities, within the two years immediately preceding the commencement of this
case.
c. If the
debtor is a corporation, list the names and addresses of all businesses in
which the debtor was a partner or owned 5 percent of more of the voting
securities, within the two years immediately preceding the commencement of this
case.
Name and Address: of business: __________________________________________
___________________________________________________________________
Nature of Business:
____________________________________________________
___________________________________________________________________
Beginning and Ending:
__________________________________________________
___________________________________________________________________
Dates of Operation:
____________________________________________________
____________________________________________________________________
______________________________________________________________________
17. Books,
records, and financial investments
None ________
a. List all
bookkeepers and accountants who within the six years immediately preceding the
filing of this bankruptcy case kept or supervised the keeping of books of
account and records of the debtor.
Name and Address:
____________________________________________________
____________________________________________________________________
Dates Service Rendered:
_________________________________________________
None _________
b. List all
firms or individuals who within the two years immediately preceding the filing
of this bankruptcy case have audited the books of account and records, or
prepared a financial statement of the debtor.
Name and Address:
___________________________________________________
___________________________________________________________________
Dates Services Rendered:
_______________________________________________
___________________________________________________________________
None _________
c. List all
firms who at the time of the commencement of this case were in possession of
the books of account and records of the debtor.
Name and Address: ___________________________________________________
___________________________________________________________________
None ________
List all financial institutions, creditors and other
parties, including mercantile and trade agencies, to whom a financial statement
was issued within the two years immediately preceding the commencement of this
case by the debtor.
Name and Address :
____________________________________________________
____________________________________________________________________
Date Issued: __________________________________________________________
18 Inventories
List the dates of the last two inventories taken of
your property, the name of the person who supervised the talking of each
inventory, and the dollar amount and basis of each inventor.
Date of Inventory:
_____________________________________________________
Supervisor:
__________________________________________________________
Dollar Amount of Inventory (specify cost market, or
other basis): _________________
None ________
b. List the
name and address of the person having possession of the records of each of the
two inventories reported in a., above.
Date of Inventory:
____________________________________________________
Name and Addresses of Custodian of Inventory Records: _______________________
___________________________________________________________________
19. Current
partners, officers, directors, and shareholders
None ________
Name and Address:
____________________________________________________
____________________________________________________________________
Nature of Interest:
______________________________________________________
____________________________________________________________________
Percentage of Interest:
___________________________________________________
_____________________________________________________________________
None ________
b. If the
debtor is a corporation, list all officers and directors of the corporation,
and each stockholder who directly or indirectly owns, controls, or holds 5
percent or more of the voting securities of the corporation.
Name and Address:
___________________________________________________
___________________________________________________________________
Title:
_______________________________________________________________
Nature and Percentage of Stock Ownership:
_________________________________
___________________________________________________________________
20. Former
partners, officers, directors, and shareholders
None ________
a. If the
debtor is a partnership, list each member who withdrew from the partnership
within one year immediately preceding the commencement of this case.
Name and Address:
___________________________________________________
___________________________________________________________________
Title:
_______________________________________________________________
Date of Termination:
____________________________________________________
None ________
b. If the
debtor is a corporation, list all officers or directors whose relationship with
the corporation terminated within one year immediately preceding the
commencement of this case.
Name and Address:
___________________________________________________
___________________________________________________________________
Title:
_______________________________________________________________
Date of Termination:
___________________________________________________
21.
Withdrawals from a partnership or distributions by a corporation
None ________
If the debtor is a partnership or corporation, list
all withdrawals of distributions credited or given to an insider, including
compensation in any form, bonuses, loans, stock redemptions, options exercised
and any other perquisite during one year immediately preceding the commencement
of this case.
Name and Address of Recipient; relationship to
Debtor: _________________________
1____________________________________________________________________
Date and Purpose of Withdrawal:
__________________________________________
____________________________________________________________________
Amount of Money:
_____________________________________________________
Description Value of Property:
____________________________________________
____________________________________________________________________
(If completed by an
individual or individual and spouse)
I declare under penalty of perjury that I have read
the answers contained in the foregoing statement of financial affairs and any
attachments thereto and that they are true and correct.
Date ____________
____________________________
Sole Debtor
Date ____________
______________________________
Joint Debtor
_______________________________
Signature
Certification and Signature of Non-Attorney
Bankruptcy Petition Preparer
(See 11 U.S.C. 110)
I certify that I am a bankruptcy petition preparer
as defined in 11 U.S.C. 110, that I
prepared this document for compensation, and that I have provided the debtor
with a copy of this document.
________________________________________ ___________________
Printed or Typed Name of Bankruptcy Petition
Preparer Social Security No.
________________________________
Signature
________________________________
Address
Names and Social Security numbers of all other
individuals who prepared or assisted in preparing this document:
If more than one person prepared this document,
attach additional signed sheets conforming to the appropriate Official form for
each person.
X__________________________________ __________________
Signature of Bankruptcy Petition Preparer Date
A bankruptcy petition preparer’s failure to comply
with the provisions of Title 11 and the Federal Rules of Bankruptcy Procedure
may result in fines or imprisonment or both.
11 U.S.C. 110; 18 U.S.C. 156.
(If Completed by on behalf of a partnership or
corporation)
I declare under penalty of perjury that I have read
the answers contained in the foregoing statement of financial affairs and any
attachments thereto and that they are true and correct to the best of my
knowledge, information, and belief.
Date _______________
_____________________________________
Signature
______________________________________
Print Name and Title
(An individual signing an behalf of a partnership or
corporation must indicate position or relationship to debtor.)
________ continuation sheets attached.
Penalty for making false statement: Fine of Up to $500,00, imprisonment for up
to 5 years, or both. 18 U.S.C. 152 and 3571.
