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Statement of Financial Affairs
Name
*
First
Last
Income from Employment or a Business
*NOTE - If you have filed tax returns for the past 2 years you can skip reporting income in the "Last Year" and "2 Years Ago" column below.
Your Gross Wages
List your gross wages by year.
This Year
Last Year
2 Years Ago
Your Spouse's Gross Wages
List your spouse's gross wages by year.
This Year
Last Year
2 Years Ago
Business Income
List your spouse's gross wages by year.
This Year
Last Year
2 Years Ago
If you were not required to file a tax return in any of the previous 2 years, please state the year(s) and the reason(s) why you were not required to file.
Other Income
Check any forms of income you (& your spouse) received in the years 2015, 2014 & 2013.
Ex.) If you are filing in 2015 and received your 2012 Federal tax refund in 2013, check "Federal Tax Refund."
Federal Tax Refund
State Tax Refund
Interest Income
Child Support
Alimony
Disability
Food Stamps
Unemployment
Adoption Subsidies
Annuities
Pension
Social Security
Other
If you checked a form of income above enter the following
Ex.) Federal Tax Refund, 2014, $4,500
Checked Form of Income
Year Received
Amount
Checked Form of Income
Year Received
Amount
Checked Form of Income
Year Received
Amount
Checked Form of Income
Year Received
Amount
Checked Form of Income
Year Received
Amount
Checked Form of Income
Year Received
Amount
Checked Form of Income
Year Received
Amount
Checked Form of Income
Year Received
Amount
Payments To Creditors
In the last 90 days, have you paid any single creditor more than $600 in total?
Yes
No
If yes...
Creditor
Address
Date of Payment(s)
Amount Paid
Amount Still Owing
If yes...
Creditor
Address
Date of Payment(s)
Amount Paid
Amount Still Owing
If yes...
Creditor
Address
Date of Payment(s)
Amount Paid
Amount Still Owing
Were any of these payments for a domestic support obligation or an alternative repayment schedule under a plan by an approved nonprofit budget & credit counseling agency?
Yes
No
Payments to Friends or Family Members
Have you made payments to any friends, family members or business partners you owe money to in the past year? (365 days)
Yes
No
If yes...
Creditor
Relationship to you
Address
Date of Payment(s)
Amount Paid
Amount Still Owing
If yes...
Creditor
Relationship to you
Address
Date of Payment(s)
Amount Paid
Amount Still Owing
If yes...
Creditor
Relationship to you
Address
Date of Payment(s)
Amount Paid
Amount Still Owing
Lawsuits
Have you been a party in a lawsuit in the past year? (365 days)
A lawsuit includes the following legal proceedings: debt collection, foreclosure, garnishment, civil (breach of contract, personal injury, etc.), class action, criminal, divorce, and child support modification.
Yes
No
If yes...
Name of Parties (who vs. who)
Case #
Type
Court
Status
If yes...
Name of Parties (who vs. who)
Case #
Type
Court
Status
If yes...
Name of Parties (who vs. who)
Case #
Type
Court
Status
If yes...
Name of Parties (who vs. who)
Case #
Type
Court
Status
Wage Garnishments, Seizures
Have you had any wage garnishments or seizures in the past year? (365 days)
Yes
No
If yes...
Creditor
Address
Seizure Date
Description of Property
Value of Property
If yes...
Creditor
Address
Seizure Date
Description of Property
Value of Property
Repossessions, Foreclosures
Have you experienced a repossession, foreclosure, deed in lieu of foreclosure, or return of a home to the seller within the past year? (365 days)
Yes
No
If yes...
Creditor
Address
Seizure Date
Description of Property
Value of Property
If yes...
Creditor
Address
Seizure Date
Description of Property
Value of Property
If yes...
Creditor
Address
Seizure Date
Description of Property
Value of Property
Assignments
Have you assigned any property for the benefit of a creditor within the past 120 days?
Yes
No
If yes...
Creditor
Address
Date of Assignment
Terms of Assignment
Custodian, Receiver
Has your property been in the possession of a custodian, receiver, or court-appointed official in the past year? (365 days)
Yes
No
If yes...
Creditor
Address
Date of Order
Court
Case Title
Case #
Description of Property
Value of Property
Gifts, Charity
Have you made gifts or charitable contributions within the past year (365 days)
Exclude regular gifts to family members totaling less than $200 per family member and charitable contributions totaling less than $100 per charity (including church, temple, etc.)
Yes
No
If yes...
Recipient
Address
Relationship to you
Date / Frequency of Gift
Description of Gift
Value of Gift
If yes...
Recipient
Address
Relationship to you
Date / Frequency of Gift
Description of Gift
Value of Gift
Losses
Have you incurred losses from gambling, fire, theft or other casualty in the past year? (365 days)
Yes
No
If yes...
Description of Property
Value
Description of Circumstances
Date of Loss
Covered by insurance
If yes...
Description of Property
Value
Description of Circumstances
Date of Loss
Covered by insurance
Debt Counseling Payments
Check next to each service you have paid in the past year (355 days)
Credit Counseling (the first course you completed)
Debt Counseling
Debt Consolidation
Bankruptcy Petition Preparer
OTHER bankruptcy attorneys
If you checked above...
Service / Attorney
Date Paid
Amount
Still Due
If you checked above...
Service / Attorney
Date Paid
Amount
Still Due
If you checked above...
Service / Attorney
Date Paid
Amount
Still Due
Transferred & Sold Property
Have you transferred or sold property (other than in the ordinary course of business or financial affairs) within the past 2 years?
Yes
No
If yes...
Recipient
Address
Relationship to you
Transfer/Sale Date
Description of Property
Value of Property
If yes...
Recipient
Address
Relationship to you
Transfer/Sale Date
Description of Property
Value of Property
Self-Settled Trust
Have you transferred any property into a self-settled trust or similar device in which you are the beneficiary within the past 10 years?
Yes
No
If yes, explain...
Closed Financial Accounts
Have you closed, sold or transferred any financial or bank accounts held in your name in the past year? (365 days)
Include checking, savings, certificates of deposit, credit union shares, and pension funds.
Yes
No
If yes...
Institution
Address
Type of Account
Account #
Final Balance
Date Closed
If yes...
Institution
Address
Type of Account
Account #
Final Balance
Date Closed
If yes...
Institution
Address
Type of Account
Account #
Final Balance
Date Closed
If yes...
Institution
Address
Type of Account
Account #
Final Balance
Date Closed
Safe Deposit Box
Do you have a safe deposit box?
Yes
No
Did you have a safe deposit box in the past year?
Yes
No
If yes to either of the safe deposit box questions...
Institution
Address
Persons with access
Their address
Contents
Date of transfer/surrender
If yes to either of the safe deposit box questions...
Institution
Address
Persons with access
Their address
Contents
Date of transfer/surrender
Setoffs
Have you experienced a setoff by a creditor, including a bank, against a debt or deposit in the past 90 days?
Yes
No
If yes...
Creditor
Address
Date of Setoff
Amount
If yes...
Creditor
Address
Date of Setoff
Amount
Property Held For Another Person
Do you hold or control another person's property?
Ex.) you drive someone else's car.
Yes
No
If yes...
Owner
Address
Property
Location of Property
If yes...
Owner
Address
Property
Location of Property
Addresses in Past 3 Years
Have you moved in the past 3 years?
Yes
No
If you have moved in the past 3 years, list the ADDRESS and DATES OF OCCUPANCY for each residence during the past 3 years.
Spouse, Former Spouse in Community Property State
IF you reside or resided in a community property state, commonwealth, or territory (including Alaska, Arizona, California, Idaho, Louisiana, Nevada, New Mexico, Puerto Rico, Texas, Washington, or Wisconsin) within the 8 year period immediately preceding the commencement of your bankruptcy, identify the name of your spouse and of any former spouse who resides or resided with you in the community property state.
Hazardous Materials
Are you in possession of any hazardous material that could cause a violation of environmental law, or have your previously caused a violation of environmental law?
Yes
No
Bankruptcy Attorney
Adam Garcia
Bankruptcy Attorney
(916) 500-0704
Mon-Sat
8 AM – 6 PM
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