STATEMENT
OF FINANCIAL AFFAIRS
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 12 or 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: _____________________
State
the gross amount of income the debtor has received from employment, trade, or
profession, or from operation of the debtors 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): _____________________________
__________________________________________________________________
__________________________________________________________________
3.
Payments to creditors
a. List 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: _________________________________________________
________________________________________________________________
________________________________________________________________
Dates
of Payments: _________________________________________________
________________________________________________________________
________________________________________________________________
Amount
paid: _______________________________________________________
_________________________________________________________________
Amount
Still Owing: __________________________________________________
_________________________________________________________________
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.)
Naming
and address of owing of creditor; relation to debtor: _____________________
___________________________________________________________________
___________________________________________________________________
Dates
of payments: ____________________________________________________
___________________________________________________________________
___________________________________________________________________
Amounts
paid: _________________________________________________________
____________________________________________________________________
Still
amounts 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
and proceedings: _________________________________________________
____________________________________________________________________
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(s)
of seizure, description and value: __________________________________
_________________________________________________________________
_________________________________________________________________
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 creditor or seller: ____________________________________
___________________________________________________________________
Date(s)
of repossession (foreclosure, sale, transfer or return):
____________________________________________________________________________________________________________________________________________
Description
of value (property): ____________________________________________
____________________________________________________________________
____________________________________________________________________
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, & number: _____________________________
____________________________________________________________________
Date
of order: __________________________________________________________
_____________________________________________________________________
Description
of property and value: __________________________________________
____________________________________________________________________
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 or Organization: _______________________________
__________________________________________________________________
Relationship
to Debtor if any: _____________________________________________
___________________________________________________________________
Date
of Gift (description and value):
________________________________________
____________________________________________________________________
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 f property: __________________________________________
___________________________________________________________________
Description
of circumstances and if loss was covered in whole 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 Relation to Debtor: ___________________________
____________________________________________________________________
Date
description 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
of Address and Date joined Institution: _______________________________
__________________________________________________________________
Type
and Number of Account and Amount of
Financial Balance: _________________
___________________________________________________________________
Amount
and 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: ___________________________________
____________________________________________________________________
Name
and address of those with Access of those to box or depository: ______________
____________________________________________________________________
Description
of content: ___________________________________________________
______________________________________________________________________
Date
of Transfer or Surrender: ______________________________________________
_____________________________________________________________________
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 Setoff: _______________________________________________________
_____________________________________________________________________
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 include Location: ___________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
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
and Names, Used .and, Include the Date 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
ending Include Address _____________________________________________
_____________________________________________________________________
Nature
of Business and 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 include Dates Service(s) 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 and 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. If any of the
books of account and records are not available, explain.
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 and 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: ________________________
___________________________________________________________________
Date
and Purpose of Withdrawal: _________________________________________
___________________________________________________________________
(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
____________________
_________________________________
Debtors
Signature
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(s)
______________________________________________ _______________
Printed
or Typed Name of Bankruptcy Petition Preparer Social Security No.
___________________________________________________
___________________________________________________
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.
___________________________
___________________
Print
Name and Title Date
___________________________
Signature
(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.
