STATEMENT OF FINANCIAL AFFAIRS

STATEMENT OF FINANCIAL AFFAIRS

NON-BUSINESS DEBTOR

UNITED STATES BANKRUPTCY COURT

FOR THE DISTRICT OF __________

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

The term, original petition, used in the following questions, shall mean the petition filed under Rule 1002, 1003, or 1004.

1. Name and residence.

a. What is your full name? ________________________________________________

Have you used, or been known by, any other names within the six years immediately preceding the filing of the original petition? (If so, give particulars.)

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b. Where do you now reside? _____________________________________________

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c. Where else have you resided during the six years immediately preceding the filing of the original petition?

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2. Occupation and income.

a. What is your occupation? ______________________________________________

b. Where are you now employed? (Give the name and address of your employer, or the address at which you carry on your trade or profession, and the length of time you have been so employed or engaged.) ____________________________________________

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c. Have you been in a partnership with anyone, or engaged in any business during the six years immediately preceding the filing of the original petition? (If so, give particulars, including names, dates, and places.) _______________________________

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d. What amount of income have you received from your trade or profession during each of the two calendar years immediately preceding the filing of the original petition?

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e. What amount of income have you received from other sources during each of these two years? (Give particulars, including each source, and the amount received.)

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3. Tax returns and refunds.

a. Where did you file your federal, state, and municipal income tax returns for the two years immediately preceding the filing of the original petition?

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b. What tax refunds (income and other) have you received during the year immediately preceding the filing of the original petition?

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c. To what tax refunds (income or other), if any, are you, or may you be, entitled? (Give particulars, including information as to any refund payable jointly to you and your spouse or any other person.)

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4. Financial accounts, certificates of deposit, and safe deposit boxes.

a. What 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 have you maintained, alone or together with any other person, and in your own or any other name within the two years immediately preceding the filing of the original petition? (Give the name and address of each institution, the name and number under which the account or certificate is maintained, and the name and address of every other person authorized to make withdrawals from such account.)

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b. What safe deposit box or boxes or other depository or depositories have you kept or used for your securities, cash, or other valuables within the two years immediately preceding the filing of the original petition? (Give the name and address of the bank or other depository, the name in which each box or other depository was kept, the name and address of every other person who had the right of access, a brief description of the contents, and, if the box has been surrendered, state when surrendered, or, if transferred, when transferred, and the name and address of the transferee.) ____________________

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5. Books and records.

a. Have you kept books of account or records relating to your affairs within the two years immediately preceding the filing of the original petition in bankruptcy?

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b. In whose possession are these book or records? (Give names and addresses.) ____________________________________________________________________

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c. If any of these books or records are not available, explain. _____________________

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d. Have any books of account or records relating to your affairs been destroyed, lost, or otherwise disposed of within the two years immediately preceding the filing of the original petition? (If so, give particulars, including date of destruction, loss, or disposition, and reason for such.)

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6. Property held for another person.

What property do you hold for any other person? (Give name and address of each person, and describe the property, or its value, and all writings relating to the property.)

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7. Property held by another.

Is any other person holding anything of value in which you have an interest? (Give name and address, location and description of the property, and circumstances of the holding.) ______________________________________________________________

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8. Prior bankruptcy.

What cases under the Bankruptcy Act or Title 11, United States Code have previously been brought by or against you? (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.) ____________________________________________________________

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9. Receiverships, general assignments, and other modes of liquidation.

a. Was any of your property, at the time of the filing of the original petition, in the hands of a receiver, trustee, or other liquidating agent? (If so, give a brief description of the property, the name and address of the receiver, trustee, or other agent, and, if the agent was appointed in a court proceeding, the name and location of the court, the title and number of the case, and the nature of the case.)

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b. Have you made any assignment of your property for the benefit of your creditors, or any general settlement with your creditors, within one year immediately preceding the filing of the original petition? (If so, give dates, the name and address of the assignee, and a brief statement of the terms of assignment or settlement.) ___________________

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110. Suits, executions, and attachments.

a. Were you a party to any suit pending at the time of the filing of the original petition? (If so, give the name and location of the court and the title and nature of the proceeding.)___________________________________________________________

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b. Were you a party to any suit terminated within the year immediately preceding the filing of the original petition? (If so, give the name and location of the court, the title and nature of the proceeding, and the result.) __________________________________

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c. Has any of your property been attached, garnished, or seized under any legal or equitable process within the year immediately preceding the filing of the original petition? (If so, describe the property seized or person garnished, and at whose suit.)

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11.(a) Payment of loans, installment purchases, and other debts.

What payments in whole or in part have you made during the year immediately preceding the filing of the original petition on any of the following: (1) loans; (2) installment purchases of goods and services; and (3) other debts? (Give the names and addresses of the persons receiving payment, the amounts of the loans or other debts and the purchase price of the goods and services, the dates of the original transactions, the amounts and dates of payments and, if any of the payees are your relatives or insiders, the relationship; if the debtor is a partnership and any of the payees is or was a partner or a relative of a partner, state the relationship; if the debtor is a corporation and any of the payees is or was an officer, director, or stockholder, or a relative of an officer, director, or stockholder, state the relationship.) ________________________________

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(b) Setoffs.

What debts have you owed to any creditor, including any bank, which were set off by that creditor against a debt or deposit owing by the creditor to you during the year immediately preceding the filing of the original petition? (Give the names and addresses of the persons setting off such debts, the dates of the setoffs, the amounts of the debts owing by you and to you and, if any of the creditors are your relatives or insiders, the relationship.) _________________________________________________

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12. Transfers of property.

a. Have 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.) __________________________________________________________

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b. Have 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 received, if any, and the disposition of such consideration.) __________________________________________

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13. Repossessions and returns.

Has any property been returned to, or repossessed by, the seller or by a secured party during the year immediately preceding the filing of the original petition? (If so, give particulars, including the name and address of the party getting the property and its description and value.) ___________________________________________________

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14. Losses.

a. Have you suffered any losses from fire, theft, or gambling during the year immediately preceding or since the filing of the original petition? (If so, give particulars, including dates, names, and places, and the amounts of money or value and general description of property lost.) ________________________________________

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b. Was the loss covered in whole or part by insurance? (If so, give particulars.)

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15. Payments or transfers to attorneys.

a. Have you consulted an attorney during the year immediately preceding or since the filing of the original petition? (Give dates, name, and address.)

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b. Have you during the year immediately preceding or since the filing of the original petition paid any money or transferred any property to the attorney or to any other person on his or her behalf? (If so, give particulars, including amount paid or value of property transferred and date of payment or transfer.)

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c. Have you, either during the year immediately preceding or since the filing of the original petition, agreed to pay any money or transfer any property to an attorney at law, or to any other person on his or her behalf? (If so, give particulars, including amount and terms of obligation.) ___________________________________________

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I, ______________________________________, declare under penalty of perjury that I have read the answers contained in the above statement of financial affairs and that they are true and correct to the best of my knowledge, information, and belief.

Dated: ______________.

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Signature

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Witness