Bankruptcy Worksheet

Full Name: *
Spouse Full Name:
Address:
Home Phone
Work Phone
Cell Phone
Work Phone (Spouse)
Cell Phone (Spouse)
E-mail *
Household members:
Total number of persons living in your house or apartment
Number of non-related persons living in your house or apartment.
Number of your children or step-children living in your house or apartment under the age of 18. (Do not include nieces, nephews or grandchildren, unless you have a guardianship or they are placed there by the court)
Total Money Received for previous six calendar months:

List your total money received from ALL sources during the previous 6 months. For each source list the total money received or gross income before deductions. List money received from wages or salaries, tax refunds, pensions, profit sharing plans, rent, food stamps, social security, disability insurance payments, commissions, child support, alimony, unemployment, internet sales, investment income, etc.

If you received money from other persons living in your house of apartment as rent or contribution toward housing costs, utilities etc., include this money in your list of money received.

Also, if you are an independent contractor or are self-employed, list the total money received before deductions.

Name of Source	Total money received in previous 6 months

Money You Are Now Receiving Monthly: Use the same definition for sources used above. However only list money you are currently receiving. This may be different because of a tax refund you received several months ago that is not part of the money you are currently receiving or perhaps there has been a change in employment, etc.

Name of Source	Payment Schedule	Average Gross/Check	Average Net/Check

Your Home

Rent	1st Mortgage	Mobile/Manufactured Home	Monthly Payment:
Condo/Association fees	2nd Mortgage	Lot Rent	Monthly Payment:

Current market value of your home - this is the amount you could reasonably expect to sell your home for today, considering the age of the home, its size and current condition.
Balance due on 1st Mortgage or Loan
Balance due on 2nd Mortgage or Loan
Balance due for Property Taxes
Amount due for Delinquent 1st Mortgage payments
Amount due for Delinquent 2nd Mortgage payments
Property taxes included with your mortgage payment? (yes/no)
Home Owners insurance included with your mortgage? (yes/no)
Vehicles, RVs, Boats, Snowmobiles, etc.: Current value for a vehicle is the amount you could purchase a similar vehicle for, considering the type of vehicle, the miles on the vehicle and the vehicles current condition.

Year	Make	Model	Payment $
Miles	Current Value	Loan Balance	Lease y/n	Free & Clear y/n

Year	Make	Model	Payment $
Miles	Current Value	Loan Balance	Lease y/n	Free & Clear y/n

Year	Make	Model	Payment $
Miles	Current Value	Loan Balance	Lease y/n	Free & Clear y/n

Average Monthly Expenses: Review your total expenses for each of these categories over the past year and estimate the average spent per month. For this part of the worksheet do not include payments on unsecured debt, such as credit cards or personal loans, delinquent medical bills, delinquent property taxes, etc.
Utilities, Electricity and heating costs
Water and sewer
Telephone including cell phones
Other utilities including internet, cable, satellite TV, trash, etc
Home maintenance (repair and upkeep)
Food
Clothing
Laundry and dry cleaning
Medical and dental expenses
Transportation, fuel and maintenance (do not include vehicle payments)
Recreation, clubs, entertainment, newspapers, magazines, etc.
Charitable contributions
Insurance (not deducted from your wages or included in your mortgage payments)
Home owners or renters
Life
Health
Vehicle (total for all vehicles, RVs, boats, travel trailers, etc.)
Other
Taxes (not deducted from your wages or included in your mortgage payments)
Specify
Alimony, maintenance and support paid to others and not deducted from wages
Payments for support of additional dependents not living with you
Regular expenses from operation of business, profession, or farm
Other monthly expenses
Other Assets Not Listed Above: List any household good or furnishing with a current market value over $500.00. List any fur or jewelry item with a current market value over $500.00. List any other asset not listed above including any real property, boats, jet skis, snowmobiles, trailers, RVs, stocks, bonds, IRAs, 401ks, pensions, profit sharing plans, etc with a value over $250.00. Where I have asked for the current market value, you may also think of this as the replacement value. Replacement value is the price a retail merchant would charge for an item of that kind, considering the age and conditions of the property. As most retail stores do not sell used items, use the price you would expect to find at a used furniture store, second hand store, or pawn shop.
Description Current Value
Debts: Summarize all debts not listed above
Credit Cards Credit card purchase in last 6 months
Medical Bills
Signature Loans
Payday Loans
Student Loans
Any other debt not already listed
Payments to relatives or on a relatives account: Please enter the total of all loan repayments to relatives during the past 12 months. Also, if you made charges on a relative's account, include all money you that repaid on that account during the past 12 months. If none, write none.
County of Residence: What county do you live in?
Private Bankruptcy
DECLARATION
I declare that my statements are true and complete to the best of my information, knowledge and belief or represent my best recollection or estimate.
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Bankruptcy Worksheet

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