Questionnaire #7 - Statement of Financial Affairs

This Questionnaire is for your Statement of Financial Affairs.Please answer the following the best you can. Anything skipped will create a new questionnaire and edits, so please don't skip questions without reviewing for accuracy.

This Form cannot be submitted until the missing fields (labelled below in red) have been filled in
Questionnaire 7 - Statement of Financial Affairs
Name*
Email Address*
Debtor's ytd gross wages from all jobs
Debtor's last years gross wages from all jobs
Debtor's year before gross wages from all jobs
Joint Debtor's ytd gross wages from all jobs
Joint Debtor's last years gross wages from all jobs
Joint Debtor's year before gross wages from all jobs
Check if either received child support	Debtor's Child Support or Alimony Joint Debtor's Child Support or Alimony
Child support or Alimony - ytd (specify what & amount)
Child support or Alimony - last year
Child support or Alimony - year before
Check if either received unemployment	Husband's unemployment Wife's unemployment
Unemployment - ytd
Unemployment - last year
Unemployment - year before
Check if either are self employed	Debtor Co-debtor Joint self employment
Self Employment - ytd gross and net
Self Employment - last year gross and net
Self Employment - year before gross and net
Your section - any other income information or comments
Have you moved in the last two years	Debtor Joint Debtor Both
Please list previous addresses, dates of occupancy and any other names used.
Have you been sued in the last twelve months?
YES NO
If yes please enter the name of the case, case number, the court name and address, and the status.
Have you had property repossessed in the past 12 months?
YES NO
Have you had a loss from fire, theft or gambling in the last 12 months?
YES NO
Have you paid anyone besides me for debt or bankruptcy counseling in the last year?
YES NO
Have you been garnished in the past 12 months?
YES NO
Have you given away property in the past 12 months?
YES NO
Have you transfered property out of your name in the past 12 months (car, house, etc)
YES NO
Have you closed out a checking or savings account in the past 12 months?
YES NO
Have you held a safe deposit box in the last 12 months with valuables, cash, etc?
YES NO
Have you had anything to do as a owner of any type of business in the past six years?
YES NO
If you answered yes, please explain.

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Rica Jo Ann Gilmore, Broker, Realtor®  

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