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CHAPTER 13

STATEMENT OF FINANCIAL AFFAIRS

UNITED STATES BANKRUPTCY COURT

FOR THE DISTRICT OF __________

Each question must be answered or the failure to answer explained. If the answer is none or not applicable, state that in the space given. If additional space is needed for the answer to any question, a separate sheet, properly identified and made a part of this document may be used and attached.

The term original petition, used in the following questions, means the original petition filed under Section 301 of the Code or, if the Chapter 13 case was converted from another chapter of the Code, shall mean the petition by or against you which originated the first case.

This form must be completed in full whether a single or a joint petition is filed. When information is requested for each or either spouse filing a petition, it should be supplied for both when a joint petition is filed.

1. Name and residence. ___________________________________________________ ______________________________________________________________________

a. Give full name.

Husband (or, if single, Debtor) _________________________

Wife ___________________________________________

b. Where does debtor, if single, or each spouse filing a petition now reside?

(1) Mailing address of husband (or debtor)

___________________________________________________________________

City or town, state and zip code

___________________________________________________________________

(2) Mailing address of wife

___________________________________________________________________

City or town, state and zip code

___________________________________________________________________

(3) Telephone number including area code

Husband (or, if single, Debtor) ___________________________________________

Wife _______________________________________________________________

c. What does debtor, if single, or each spouse filing a petition consider his or her residence, if different from that listed in b, above?

Husband (or Debtor) _________________________________________________

Wife ______________________________________________________________

2. Occupation and income.

a. Give present occupation of debtor, if single, or of each spouse filing a petition. (If more than one, list all for debtor or each spouse filing a petition.)

Husband (or Debtor) __________________________________________________

Wife ______________________________________________________________

b. What is the name, address, and telephone number of the present employer (or employers) of debtor, if single, or of each spouse filing a petition? (Include also any identifying badge or card number with employer.)

Husband (or Debtor) __________________________________________________

Wife ______________________________________________________________

c. How long has debtor, if single, or each spouse filing a petition been employed by present employer?

Husband (or Debtor) ___________________________________________________

Wife ________________________________________________________________

d. If debtor or either spouse filing a petition has not been employed by his or her present employer for a period of one year, state the name of prior employer(s) and nature of employment during that period.

Husband (or Debtor) ___________________________________________________

Wife ________________________________________________________________

e. Has debtor or either spouse filing a petition operated a business, in partnership or otherwise, during the past three years? (If so, give the particulars, including names, dates, and places.)

Husband (or Debtor) ___________________________________________________

Wife ________________________________________________________________

f. Answer the following questions for debtor, if single, or for each spouse whether single or joint petition is filed unless spouses are separated and a single petition is filed:

(1) What are your gross wages, salary, or commissions per pay period?

Husband Wife

(or Debtor)

(a) Weekly __________ __________

(b) Semi-monthly __________ __________

(d) Other (specify) __________ __________

(2) What are your payroll deductions per pay period for:

Husband Wife

(or Debtor)

(a) Payroll taxes

(including

social security) __________ __________

(b) Insurance __________ __________

(d) Union dues __________ __________

(e) Other (specify) __________ __________

(3) What is your take-home pay per pay period?

Husband Wife

(or Debtor)

__________ __________

(4) What was the amount of your gross income for the last calendar year?

Husband Wife

(or Debtor)

__________ __________

(5) Is your employment subject to seasonal or other change?

Husband Wife

(or Debtor)

__________ __________

(6) Has either of you made any wage assignments or allotments? (If so, indicate which spouses wages here assigned or allotted, the name and address of the person to whom assigned or allotted, and the amount owing, if any, to such person. If allotment or assignment is to a creditor, the claim should also be listed in Item 11a.) ________________________________________________________________

3. Dependents. (To be answered by debtor if unmarried, otherwise for each spouse whether single or joint petition is filed unless spouses are separated and a single petition is filed.)

a. Do either of you pay (or receive) alimony, maintenance, or support? __________ If so, how much per month? __________ For whose support?

(Give name, age, and relationship to you.)

Husband (or Debtor) _________________________________________________

Wife ______________________________________________________________

b. List all other dependents, other than present spouse, not listed in a, above. (Give name, age and relationship to you.)

Husband (or Debtor) __________________________________________________

Wife _______________________________________________________________

4. Budget.

a. Give your estimated average future monthly income, if unmarried, otherwise for each spouse whether single or joint petition is filed, unless spouses are separated and a single petition is filed.

(1) Husbands (or Debtors) monthly take-home pay ___________

(2) Wife’s monthly take-home pay ___________

(3) Other monthly income (specify) ___________

___________

Total

===========

b. Give estimated average future monthly expenses of family (not including debts to be paid under plan), consisting of:

(1) Rent or home mortgage payment (include lot rental for trailer) __________

(2) Utilities Electricity __________

Heat __________

Water __________

Telephone __________

(3) Food __________

(4) Clothing __________

(5) Laundry and cleaning

(6) Newspapers, periodicals,

and books (including school books) __________

(7) Medical and drug expenses __________

(8) Insurance (not deducted

from wages)

(a) Automobile __________

(b) Other __________

(9) Transportation (not

including automobile payments

to be paid under plan) __________

(10) Recreation __________

(11) Dues, union, professional,

social or otherwise (not

deducted from wages) __________

(12) Taxes (not deducted

from wages) __________

(13) Alimony, maintenance, or

support payments __________

(14) Other payments for support

of dependents not living

at home __________

(15) Religious and other

charitable contributions _________

(16) Other (specify) _________

_________

Total ===========

c. Excess of estimated future

monthly income (last line of

Item 4a, above) over estimated

future expenses (last line of

Item 4b, above) __________

d. Total amount to be paid each

month under plan __________

5. Payment of attorney.

a. How much have you agreed to pay

or what property have you agreed

to transfer to your attorney in

connection with this case? __________

b. How much have you paid or what

have you transferred to the

attorney? __________

6. Tax refunds. (To be answered by debtor, if unmarried, otherwise for each spouse whether single or joint petition is filed, unless spouses are separated and a single petition is filed.) To what tax refunds (income or other), if any, is either of you, or may either of you be, entitled? (Give particulars, including information as to any refunds payable jointly to you or any other person. All such refunds should also be listed in Item 13b.)

_________________________________________________________________

7. Financial accounts, certificates of deposit and safe deposit boxes. (To be answered by debtor, if unmarried, otherwise for each spouse whether single or joint petition is filed unless spouses are separated and a single petition is filed.)

a. Does either of you currently have any accounts or certificates of deposit or shares in banks, savings and loan, thrift, building and loan and homestead associations, credit unions, brokerage houses, pension funds and the like? (If so, give name and address of each institution, number and nature of account, current balance, and name and address of every other person authorized to make withdrawals from the account. Such accounts should also be listed in Item 13b.)

_______________________________________________________

b. Does either of you currently keep any safe deposit boxes or other depositories? (If so, give name and address of bank or other depository, name and address of every other person who has a right of access thereto, and a brief description of the contents, which should also be listed in Item 13b.)

________________________________________________________

8. Prior Bankruptcy.

What cases under the Bankruptcy Act or Bankruptcy Code have previously been brought by or against you or either spouse filing a petition? (State the location of the bankruptcy court, the nature and number of each case, the date when it was filed, and whether a discharge was granted or denied, the case was dismissed, or a composition, arrangement, or plan was confirmed.)

__________________________________________________________________

9. Foreclosures, executions, and attachments. (To be answered by debtor, if unmarried, otherwise for each spouse whether single or joint petition is filed unless spouses are separated and a single petition is filed.)

a. Is any of the property of either of you, including real estate, involved in a foreclosure proceeding, in or out of court? (If so, identify the property and the person foreclosing.) _____________________________________________

_______________________________________________________

b. Has any property or income of either of you been attached, garnished, or seized under any legal or equitable process within the 90 days immediately preceding the filing of the original petition? (If so, describe the property seized, or person garnished, and at whose suit.) ________________________________________

_______________________________________________________

10. Repossessions and returns. (To be answered by debtor, if unmarried, otherwise for each spouse whether single or joint petition is filed unless spouses are separated and a single petition is filed.) Has any property of either of you been returned to, repossessed, or seized by the seller or by any other party, including a landlord, during the 90 days immediately preceding the filing of the original petition? (If so, give particulars, including the name and address of the party taking the property and its description and value.)

_______________________________________________________________

11. Transfers of Property. (To be answered by debtor, if unmarried, otherwise for each spouse whether single or joint petition is filed unless spouses are separated and a single petition is filed.)

a. Has either of you made any gifts, other than ordinary and usual presents to family members and charitable donations, during the year immediately preceding the filing of the original petition? (If so, give names and addresses of donees and dates, description and value of gifts.)

___________________________________________________________________

b. Has either of you made any other transfer, absolute or for the purpose of security, or any other disposition, of real or personal property during the year immediately preceding the filing of the original petition? (Give a description of the property, the date of the transfer or disposition, to whom transferred or how disposed of, and, if the transferee is a relative or insider, the relationship, the consideration, if any, received, and the disposition of such consideration.)

____________________________________________________________________

_____________________________________________________________________

Debts. (To be answered by debtor, if unmarried, otherwise for each spouse whether single or joint petition is filed.)

a. Debts Having Priority.

(1) (2) (3) (4) (5)

Nature Name of Specify when claim Indicate Amount

of creditor was incurred and if claim of

claim and complete the consideration is con- claim

including mailing therefor; tingent,

zip address when unliquidated,

code claim is or

subject disputed

to setoff,

evidenced by

a judgment,

negotiable

instrument, or

other writing

___________ ____________ _______________ ____________ _________

1. Wages, salary, and commissions, including vacation, severance and sick leave pay owing to employees not exceeding $2,000 to each, earned within 90 days before filing of petition or cessation of business (if earlier specify date). $__________

2. Contributions to employee benefit plans for services rendered within 180 days before filing of petition or cessation of business (if earlier specify date). $__________

3. Deposits by individuals, not exceeding $900 for each for purchase, lease, or rental of property or services for personal, family, or household use that were not delivered or provided. $__________

4. Taxes owing (itemize by type of tax and taxing authority)

(A) To the United States __________

(B) To any state __________

__________

Total __________

b. Secured Debts. List all debts which are or may be secured by real or personal property. (Indicate in sixth column, if debt payable in installments, the amount of each installment, the installment period (monthly, weekly, or otherwise) and number of installments in arrears, if any. Indicate in last column whether husband or wife solely liable, or whether you are jointly liable.)

________________________________________________________________

Credi-

tor’s

name, ac-

count Install-

number ment

and amount,

comp- Descrip- Period, House

lete tion of and hold

mailing Consi- If dis- collate- number or wife

address eration Amount puted, ral (inc- of solely

inclu- or claimed amount lude year install- liable,

ding basis by admit- and make ments or

zip for credi- ted by of auto- in jointly

code debt tor debtor mobile) arrears liable

__________ _________ __________ ________ _________ ________ ________

Total secured debts __________

c. Unsecured Debts. List all other debts, liquidated and unliquidated, including taxes, attorney’s fees, and tort claims.

__________________________________________________________________

Creditors

name, ac-

count number Husband

and complete or wife

mailing Consider- If disputed, solely

address ation or Amount amount liable,

including basis for claimed by admitted or jointly

zip code debt creditor by debtor liable

_______________ __________ __________ __________ __________

Total unsecured debts ____________________________________

13. Co-debtors. (To be answered by debtor, if unmarried, otherwise for each spouse whether single or joint petition is filed.)

a. Are any other persons liable, as cosigners, guarantors, or in any other manner, on any of the debts of either of you or is either of you so liable on the debts of others? (If so, give particulars, indicating which spouse is liable and including names of creditors, nature of debt, names and addresses of co-debtors, and their relationship, if any, to you.)

_________________________________________________________

b. If so, have the co-debtors made any payments on the debts? (Give name of each co-debtor and amount paid by co-debtor.)

_________________________________________________________

c. Has either of you made any payments on the debts? (If so, specify total amount paid to each creditor, whether paid by husband or wife, and name of co-debtor.)

_________________________________________________________

14. Property and Exemptions. (To be answered by debtor, if unmarried, otherwise for each spouse whether single or joint petition is filed.)

a. Real Property. List all real property owned by either of you at date of filing of original petition. (Indicate in last column whether owned solely by husband or wife, or jointly.)

Present Value

market claimed

value Amount exempt

Name (without of specify

of any deduction mortgage Name of federal Owned

Descrip- co- for or other mort- or state solely

tion and owner mortgage security gagee statute by

location other or other interest or other creating husband

of than security on this secured the ex- or wife

property spouse interest) property creditor emption) jointly

_____________ ___________ _______ _______ ___________ _______ _______

I, ______________________, (if joint petition is filed and I, ________________,) declare under penalty of perjury that I have read the answers contained in the above statement, consisting of __________ sheets, and that they are true and complete to the best of my knowledge, information, and belief.

Dated: __________.

____________________________________________________

Signature