Shiryak, Bowman, Anderson, Gill & Kadochnikov LLP

Bankruptcy Questionnaire

Please complete

1. Name *
1. Name
4. Phone *
4. Phone
Please pick one
7. Do you own a house?
9. Have you lived in New York for more than 180 days?
10. Case type
15. Your intention
18. Do you have a bank account?
19. If yes, is it a
22. Collections and collectibles (including antiques, furs, jewelry, books, ect..)
25. Do you have any cash value/whole life insurance?
26. Do you have any 401k, IRA or any other pension plan?
28. Do you currently own or have you had any ownership interest in any business in the last six years?
29. Have you been divorced in the past six years?
30. Does anyone owe you money?
31. Are you entitled to a tax refund?
32. Are you entitled to real estate, money, or other personal property in the event of a death or any other circumstance?
33. Automobiles, trucks, trailers, and other vehicles and accessories?
35. Do you own a boat?
37. Do you own any office equipment
39. Do you own any pets?
40. Any other personal property?
41. Garnished wages?
42. Patents, copyrights, or intellectual property?
43. Farming equipment and implements
44. Do you own any large appliances or electronics?
45. Any secured debts?
47. Do you intend to keep or surrender the property?
52. Do you receive any rental income?
53. Do you have any other sources of income?
54. Mortgage or Rent?
57. Do you pay for Health insurance?
58. Auto insurance?
61. Student loans?
63. Do you owe any alimony, maintenance or child support?
66. Child care/day care, school expenses?
68. Any other expenses?
70. Any other unsecured debts such as tax debt, medical debt, or any other creditors that will not show up in your credit report?
72. Do you have any existing contracts or contracts in progress such as a car lease, ect?
73. Do you intend to keep or surrender?
76. Have you filed taxes for the last 4 years?
77. Have you paid any creditor $600 or more in the last 90 days?
78. Has anyone sued you in the past year?
79. Have you paid back any loans to any friends or family members in the past year?
80. Have you had any property garnished or repossessed in the past 12 months?
81. Have you transferred any property in the last six years, such as cash real estate or other valuable goods?
83. Have you closed any bank accounts within the last 12 months?
84. Do you have any safe deposit boxes?
85. Have you been at your current address for more than two years?
87. Have you ever lived with your spouse in a community property tax state
Including: Alaska, Arizona, California, Idaho, Louisiana, Nevada, New Mexico, Puerto Rico, Texas, Washington, or Wisconsin
88. Have you been in any litigation regarding environmental law or the release of hazardous materials?