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Draft Form
Bankruptcy Disclosure Form
First Name
Last Name
Your Email
Phone Number
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Are you currently married?
Yes
No
Spouse's First Name
Spouse's Last Name
Spouse's Email
Spouse's Phone Number
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Have you provided to your attorney all of your previous addresses from the past 3 Years?
Yes
No
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Have you disclosed ALL sources of income, including wages, self-employment income, unemployment benefits, domestic support, legal settlements, lottery/gambling winnings, and stock earnings?
Yes
No
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Have you made any payments of $600 or more to any single creditor within the last 90 days?
Yes
No
Have you repaid debts or transferred any property to anyone you know personally within the last year?
Yes
No
Please List the debts or transferred property that you transferred within the last year to someone you personally know:
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Have you disclosed ALL recent legal actions, including lawsuits, foreclosures, wage garnishments, and repossessions?
Yes
No
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Have you given any charitable contributions or gifts in the last two years that were worth more than $600?
Yes
No
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Have you had anything stolen from you or lost anything of value within the last year due to gambling or natural/man-made disaster?
Yes
No
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Have you disclosed all payments or property transfers made to any attorney, bankruptcy petition preparer, or credit counseling services?
Yes
No
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Have you listed ALL of your financial accounts?
Yes
No
Have you provided information about the contents of safe deposit boxes and storage units you own?
Yes
No
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Have you disclosed any property owned by other people that you hold or control, even if it’s in a trust or in storage?
Yes
No
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If you own a business related to fuel, chemicals, or waste products, have you disclosed all relevant environmental information?
Yes
No
N/A
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If you’ve owned any part of a business or been tied to a business as an officer, director, or managing executive in the last four years, have you disclosed that information?
Yes
No
N/A
Have you given a financial statement to anyone concerning your business within the last two years?
Yes
No
N/A
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Do you understand that if you do not make payments for secured loans (e.g., mortgage, car loan), the creditor WILL take the property post-bankruptcy?
Yes
No
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I confirm that I have answered all questions truthfully and to the best of my knowledge.
By typing your full name below, you agree that you are signing this form electronically. You consent that this signature is legally binding and that you have answered all questions truthfully and to the best of your knowledge.
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