avery law · 2020. 6. 5. · heirlooms, baseball cards, sports memorabilia, etc. *schedule b*...
TRANSCRIPT
Idaho Falls Pocatello
770 S. Woodruff 410 Yellowstone
Idaho Falls, ID 83401 Pocatello, ID 83201
208.524.3020 208.232.3020
208.524.2051 fax 208.904.4905 fax
CHAPTER 7/13
CHAPTER 7/13
CHAPTER 13
CHAPTER 7
CHAPTER 7/13
Twin Falls Boise Metro Meridian
808 Eastland Dr. 1843 Broadway Ave. �090 E. Gentry Way
Suite B Suite 203 B Suite 150
Twin Falls, ID 83301 Boise, ID 83 706 Meridian, ID 83642
208.733.3030 208.639.9400 208.639.9400
208-944.2802 fax 208.297 .5553 fax 208.297.5553 fax
Avery Law Christine Harrop
Ami Beem
Crystal Robertson
Melissa Geary
Tina Jensen
*Please contact your case manager if you have any questions about filling out this packet*
Your full name -----------------------------
Spouse's full name ___________________________ _
Phone Number Co-Debtor Phone Number --------- ----------
Social Security Number _________________________ _
Spouse's Social Security Number ______________________ _
Email Address -----------------------------
Full Current Address ---------------------------
City, State, County, Zip _________________________ _
Other names, including business names and maiden names, used within the last 8 years
**Notice****Return of the information requested by this Avery Law questionnaire does not mean that your bankruptcy case has been filed, nor
does it mean you have established an attorney client relationship with Avery Law.
**The completion and submission of this questionnaire to Avery Law is for the sole purpose of facilitation of Avery Law's review and discussion with you as to whether bankruptcy or other representation of you by Avery Law is in fact appropriate.
**An attorney client relationship with Avery Law is only established upon the execution of a signed Avery Law Attorney Fee Agreement, or Model Retention Agreement in a Chapter 13 case, and after satisfactory payment arrangements are secured.
*Schedule A*
REAL PROPERTY
(Real estate, house, trailer, rental income properties)
Description of Nature of Debtor's Current
Interest in Market Property
Property Value
Example:
Joint owner with 770 S. Woodruff spouse $150,000
Idaho Falls, ID 83401
Amount of
Secured
Claim
$125,000
TYPE OF
PROPERTY
1. Motor vehicles:
Car, Truck, SUV
2.Recreational vehicles:
i.e. Boats, RV,
motorcycles, trailer,
ATV, snowmobile, etc.
3. Electronics:
4. Collectiblesof Value:
Heirlooms, baseball
cards, sports
memorabilia, etc.
*Schedule B*
PERSONAL PROPERTY
DESCRIPTION OF PROPERTY
I.Make: 2.Make:
Model: Model:
Year: Year:
Mileage: Mileage:
Condition: Condition:
1.Make: 2.Make:
Model: Model:
Year: Year:
Mileage: Mileage:
Condition: Condition:
TV
TV
DVD player & DVDs
Game Systems, Accessories, and Games
Computers
Phones
If you have multiple items please list them individually and
the value.
CURRENT
MARKET
VALUE
(Yard Sale
Prices)
1.$
2.$
1.$
2.$
$
$
$
CURRENT
TYPE OF MARKET
PROPERTY DESCRIPTION OF PROPERTY VALUE
(Yard Sale
Prices)
5. Books, pictures & If you have multiple items please list them individually and
other art: antiques,the value.
stamps, coins, records,
tapes
6. Sporting goods and If you have multiple items please list them individually and
hobby Equipment:the value.
Camping, fishing,
scrapbooking, sewing,
crafting supplies
7. Furs and jewelry: Misc costume Jewelry
*Including costume Wedding Rings Debtor
jewelry Wedding Rings Co-Debtor
8. Firearms: model and
caliber
9. Clothing Lump all values together for house hold sum $
10. Pets
11. Cash on hand $
CURRENT
MARKET TYPE OF
DESCRIPTION OF PROPERTY VALUE PROPERTY
(Yard Sale
Prices)
12. Checking, savingsInstitution: $
or other financiallast 4 of account:
accounts, certificates ofChecking/Savings
deposit, or shares in$
banks, savings and loan,Institution:
thrift, building and loan,last 4 of account:
$ and homestead
Checking/Savings associations, or credit
unions, brokerageInstitution:
houses, or cooperativeslast 4 of account:
& debit card accounts.Checking/Savings
13. Interests in
insurance policies.
Name insurance
company of each policy
and itemize surrender or
refund value of each.
14. Annuities. Itemize
and name each issuer.
15. Interests in an
education IRA as
defined in 26 U .S.C. §
529(b)(l). Give
particulars.-
16. Interests in IRA,
ERISA, Keogh, or all
other retirement
accounts or profit
sharing plans. Itemize.
PERSONAL PROPERTY HOUSEHOLD GOODS
1. List all items in each room and their value
2. Only list items you own (not items you are renting or that are owned by roommate, etc.)
KITCHEN
Item Value Item Value
1. Bakeware 5. Flatware
2. Cookware 6.Linens
3. Dishware 7. Decor
4. Glassware 8. Silver
DINING ROOM
Item Value Item Value
1. Dining tablechairs 4. Linens
2. China Hutch 5. Decor
3. Rug 6.
BATHROOMS
Item Value Item Value
1. Personal care items 4. Decor
2.Linens 5.
3. Shelving 6.
LIVING ROOM
Item Value Item Value
1. Couch 8. Entertainment center
2. Loveseat 9. Book shelves/Books
3. Recliner 10. Decor
4. Coffee table 11.
5. End tables12.
6. Lamps 13.
*Schedule D*
SECURED DEBTS
These creditors may repossess the property which is collateral for the loan. Examples:
mortgage, car loan, or furniture installment purchases. For real estate it is recommended to get a
real estate assessor value or tax assessed value For vehicle values use the Kelly Blue Book 2
Creditor's Name, Description of Property
Market Amount You
Address & Your Value of Owe on
Account Number and Intention for Loan
Property Property
EXAMPLE:
2006 Mazda 6 - KEEP/REAFFIRM $15,000 $11,000
East Idaho Credit LOAN
Union
865 S. Woodruff Ave.
P.O. Box 1865
Idaho Falls, ID 83403 Reaffirm Return
account# 12345678-9
$ $
Reaffirm Return --
$ $
Reaffirm Return
$ $
Reaffirm Return --
Market Amount You Creditor's Name, Description of Property
Value of Owe on Address & Your and Intention for Loan
Property Property Account Number
$ $
Reaffirm Return --
$ $
Reaffirm Return --
$ $
Reaffirm Return --
$ $
Reaffirm Return --
*Schedule E*
PRIORITY DEBTS
1. Do you or your spouse currently owe any arrears for child support, alimony, or any otherdomestic support obligation?
Yes No ---- ----
If yes, please provide us with the name of the person the money is owed to, a current or last known address for that person, and the amount of arrears owed to that person:
2. Do you or your spouse owe any money to the IRS or any state Tax Commission for unpaidtaxes?
Yes No ---- ----
If yes, please provide us with the name of the applicable agency money is owed to, the taxable year that money is owed from, and the amount of taxes owed from each individual year:
3. Do you or your spouse owe any other debts to a state or federal governmental agency?
Yes No ---- ----
If yes, please provide us with the name of the applicable agency money is owed to, the nature of the debt owed, and the amount owed:
4. Did you or your spouse, in connection with the sale, lease, or rent of property, receive a
deposit of money (such as a rental security deposit or advanced payment) from any individual?
Yes No ---- ----
If yes, please provide us with the name of the applicable agency money is owed to, the nature of the debt owed, and the amount owed:
5. If an LLC, Partnership, Corporation, or Sole Proprietorship is filing this bankruptcy does saidbusiness owe wages, benefits, or retirement plans to any employee?
Yes No NIA ---- ---- ----
If yes, please provide us with specific information regarding the number of employees, the nature of the benefit, and the amount of said benefit that is owed to the employees:
6. If an LLC, Partnership, Corporation, or Sole Proprietorship is filing this bankruptcy is saidbusiness incurring more· debt currently?
Yes No NIA ---- ---- ----
If yes, please provide us with specific information regarding the type of debt that is continuing to be assessed against the business:
*Schedule I*
EMPLOYMENT AND FAMILY INFORMATION
Debtor's Marital Status:
Married: ----
Separated: __ _
Widowed: ----
Single: ___ _
Divorced: Date of Divorce: ---- ---
Employment
Debtor Spouse
Occupation:
Name and address of
Employer:
How long employed
there:
CURRENT INCOME OF INDIVIDUAL DEBTOR(S)
INCOME: (Estimate of average monthly income) DEBTOR SPOUSE
2.Current monthly gross wages, salary, and commissions $ $
3 .Estimated monthly overtime $ $
Subtotal $ $
5 .Less payroll deductions
a.Payroll taxes, medicare and social security $ $
b.Mandatory contributions to retirement plans $ $
c.Voluntary contributions for retirement plans $ $
d.Required repayments of retirement fund loans $ $
e.lnsurance $ $
f.Domestic Support Obligations $ $
g.Union dues $ $
h.Other (specify) $ $
TOTAL NET MONTHLY TAKE HOME PAY $ $
*Schedule I (Cont.)***If you have been operating a business, please create and attach a Profit and Loss statement that
accounts for the last 6 months of income and expenses for your business. Include things such asUber, Lyft, Doordash, other sole proprietorships, LLC's, and other types of businesses.**
Gross income from operation of business
Expenses
Net income from operation of business
Income from real property Expenses
Net income from real property
Sb.Interest and dividends
Sc.Alimony, maintenance or support payments payable to the
debtor for the debtor's use or that of dependents listed above
Sd. Unemployment
Se. Social Security
S f. Other government assistance
(Specify)
Sg. Pension or retirement income
Sh. Other monthly income
(Specify)
TOTAL COMBINED MONTHLY INCOME
$ $ ---- ----
$ $ ----
$ $ __ _
$ ___
$ __ _
$ $ ----
$ $ ----
$ $
$ $
$ $
$ $
$ $
$ $
$ $
$ $
Describe any increase or decrease of more than 10% in any of the above categories
anticipated to occur within the year following the filing of this document:
over the last three years, such as wages and side business, these amounts must be
separated out into separate entries.
Debtor
YEAR AMOUNT SOURCE
Co-Debtor
YEAR AMOUNT SOURCE
4. Account for income from all other sources over the last two full years and this current
year to date. This will include all types of government benefits, retirement funds, sale
8. In the last 12 months, were you a named party in a current or concluded lawsuit, court
action, or other administrative proceeding?
Yes No ---- ----
If yes, please fill in the following table:
Case title and case number Nature of Court the case was Status of
the case handled the case
9. In the last 12 months, was any of your property or wages repossessed, foreclosed,
garnished, attached, seized, or levied?
Yes No ---- ----
If yes, please fill in the following table:
Creditor name and address Describe the property (What
Date Value of
was taken and why) Property
10. In the last 90 days, did any creditor set off any amounts from your account or refuse to
make a payment on debts because you owed a debt to them? (Generally banks)
Yes No ---- ----
If yes, please fill in the following table:
Creditor name and address Describe action the creditor Date of
Amount took occurrence
11. In the last 12 months, was any of your property assigned for the benefit of a creditor?
Yes No ---- ----
If yes, please explain:
12. In the last 24 months, have you given any gifts totaling $600 or more to a single person?
Do not include things such as birthday gifts, Christmas gifts, etc ...
Yes No ---- ----
If yes, please fill in the following table:
Person who received the gift Describe the gift Date gift
Value was given
13. In the last 24 months, have you given any charitable contributions to a charity or
religious organization totaling $600 or more?
____ Yes No ----
If yes, please fill in the following table:
Organization's name and Describe what was Date of Amount
address contributed contribution
14. In the last 12 months, have you lost any money or property due to theft, fire, other
disaster, or gambling?
Yes No ---- ----
If yes, please fill in the following table:
21. Do you currently have, or have you had in the last 12 months, any property stored in a
storage unit or place other than your home?
Yes No ---- ----
If yes, please fill in the following table:
Name and address of the Description and value of Who else has · Do you
storage facility property stored access to it? still have it
22. Do you have in your possession property that someone else owns? Include all property
you are borrowing, storing for another person, or are holding in trust.
Yes No ---- ----
If yes, please fill in the following table:
Name and address of the Description and value of property
Where is the
owner property
23. Have you ever received written notice from any city, county, state or federal
government that you may be liable or potentially liable for the violation of any
environmental law? If so, give the name of the government entity, the date of the
notice, the name and address for the property involved and if known, the
environmental law violated.
a. Have you ever provided notice to any city, county, state or the Federal
government of a release of hazardous material. If so, give the name and address
of every location where the hazardous release took place and the state where and
when the notice was sent.
b. List all judicial or administrative proceedings, including settlements or orders,
under any Environmental Law with respect to which the debtor is or was a
party. Indicate the name and address of the governmental unit that is or was a
party to the proceeding, and the docket number.
24. In the last 4 years, did you have any ownership rights or operate any business? (Include
sole-proprietorships, partnerships, being an officer of a LLC or corporation, and
having voting shares in a company)
Yes No ---- ----
If yes, please fill in the following table:
Name and address of the business Describe the nature When did the Name of
(include EIN) of the business business operate? bookkeeper
25. In the last 2 years, did you give a financial statement to anyone about your business?
Include all financial institutions, creditors, or other parties.
Yes No ---- ----
If yes, please fill in the following table:
Name and address of recipient Date statements were given
*Business Addendum*
A. Is the debtor a partnership? ____ If no skip to B. If yes, list the names, addresses,taxpayer identification numbers, nature of the businesses, and beginning and ending dates ofall businesses in which the debtor was a partner or owned 5 percent or more of the voting orequity securities, within the six years immediately preceding the commencement of this case.
B. Is the debtor a corporation? ____ If no skip to C. If yes, list the names, addresses,taxpayer identification numbers, nature of the businesses, and beginning and ending dates ofall businesses in which the debtor was a partner or owned 5 percent or more of the voting orequity securities within the six years immediately preceding the commencement of this case.
C. List all bookkeepers and accountants who, within the two years immediately preceding thefiling of this bankruptcy case, kept or supervised the keeping of books of account and recordsof the debtor.
D. List all firms or individuals who, within the two years immediately preceding the filing ofthis bankruptcy case, have audited the books of account and records, or prepared a financialstatement of the debtor.
E. List all firms or individuals who, at the time of the commencement of this case, were inpossession of the books of account and records of the debtor. If any of the books of accountand records are not available, explain.
F. List all financial institutions, creditors and other parties, including mercantile and tradeagencies, to whom a financial statement was issued within the two years immediatelypreceding the commencement of this case by the debtor.
G. List the dates of the last two inventories taken of your property, the name of the person whosupervised the taking of each inventory, and the dollar amount and basis of each inventory.
H. List the name and address of the person having possession of the records of each of the twoinventories reported in a., above.
I. If the debtor is a partnership, list the nature and percentage of partnership interest of eachmember of the partnership.
J. If the debtor is a corporation, list all officers and directors of the corporation, and eachstockholder who directly or indirectly owns, controls, or holds 5 percent or more of thevoting securities of the corporation.
K. If the debtor is a partnership, list each member who withdrew from the partnership withinone year immediately preceding the commencement of this case.
L. If the debtor is a corporation, list all officers or directors whose relationship with thecorporation terminated within one year immediately preceding the commencement of thiscase.
M. If the debtor is a partnership or corporation, list all withdrawals or distributions credited orgiven to an insider, including compensation in any form, bonuses, loans, stock redemptions,options exercised and any other perquisite during one year immediately preceding thecommencement of this case.
N. If the debtor is a corporation, list the name and federal taxpayer identification number of theparent corporation of any consolidated group for tax purposes of which the debtor has been amember at any time within the six-year period immediately preceding the commencement ofthe case.
0. If the debtor is not an individual, list the name and federal taxpayer identification number ofany pension fund to which the debtor, as an employer, has been responsible for contributingat any time within the six-year period immediately preceding the commencement of the case.
Additional Information From Any Previous Field