Questions For Debtor's Examination
1.

What is your full name and your spouse’s full name (if married):

________________________________________________________

________________________________________________________

   
2.

Have you ever used another name on any documents such as a driver’s license, credit application or other important paper? If so:

• Give name:______________________________________________

________________________________________________________

• Give location and approximate time when name was used:__________

________________________________________________________

   
3.

What is you current address and length of time you have lived there:____

________________________________________________________

________________________________________________________

   
4.

What was your previous address:______________________________

________________________________________________________

   
5.

What are your current phone numbers: Home (     )__________________

Work (     )_______________________Cell (     )__________________

   
6. What were your previous phone numbers: Home (     )_______________

Work (     )_______________________Cell (     )__________________

   
7. What is your California driver’s license (or California identification card) number: _________________________________________________
   
8. What is your social security number:____________________________
   
9. What is your date of birth:____________________________________
   
10.

If married, what is your spouse’s maiden name: ___________________

________________________________________________________

   
11. Are you employed as an employee, either part time or full time? If so:

• Name, address and phone number of employer:__________________

________________________________________________________

________________________________________________________

• Frequency of payroll check (weekly, bi-weekly, monthly, etc.):

________________________________________________________

• Gross pay: $_____________________________________________

• Take home pay: $_________________________________________

• Commissions, if any: ______________________________________

________________________________________________________

• How much is due you at the present time: $______________________

• How long on this job: ______________________________________

   
12.

Where and with whom was your previous job:_____________________

________________________________________________________

   
13.

Do you perform labor or services for someone else as an independent contractor rather than as an employee? If so:

• Names, addresses, and phone numbers of persons or businesses for whom you perform services:

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

• Nature of services performed for each such person or business:______

________________________________________________________

________________________________________________________

• Frequency of services: _____________________________________

________________________________________________________

• Method of billing (e.g., flat rate, hourly rate, job rate): _______________

________________________________________________________

 

14.

Do you own a business (in whole, in part, as a partner, or as a corporation), or have you owned a business within the past five years? If so:

• Describe the business: ____________________________________

________________________________________________________

________________________________________________________

• Who you do business with: __________________________________

________________________________________________________

________________________________________________________

• Describe major people or businesses who owe you money (names, addresses and telephone numbers): ___________________________

________________________________________________________

________________________________________________________

________________________________________________________

• Describe any business assets such as tools, equipment, computers, furniture, fixtures, machinery, etc. wholly owned by the business:

________________________________________________________

________________________________________________________

________________________________________________________

• Identify which of these assets you still owe money on and the approximate amount owed: __________________________________

________________________________________________________

________________________________________________________

• Describe, generally, method of doing business: __________________

________________________________________________________

________________________________________________________

________________________________________________________

• Provide names and addresses of partners (if the business is a partnership), and corporate officers (if the business is a corporation):

________________________________________________________

________________________________________________________

________________________________________________________

   
15. Do you own stock in any corporation? If so:

• Name of corporation: ______________________________________

________________________________________________________

• Location of stock certificates: ________________________________

________________________________________________________

• Amount of ownership and approximate value: ____________________

________________________________________________________

 

   
16.

Do you maintain a brokerage account with any stock broker? If so:

• Name and address of broker: _______________________________

________________________________________________________

• Account number(s): _______________________________________

________________________________________________________

• Approximate amount in brokerage account: _____________________

________________________________________________________

 

17.

Do you or your spouse have any funds in banks, savings and loans, money market accounts, certificates of deposit, escrow accounts, credit unions, or any other financial institutions, either in your name or jointly with any other individual? If so:

• Name of each financial institution and address of branch possessing the funds: ________________________________________________

________________________________________________________

________________________________________________________

• The account number of each account:__________________________

________________________________________________________

________________________________________________________

• Name(s) the account is under: _______________________________

________________________________________________________

• The approximate balance in the account: _______________________

________________________________________________________

• Date the last deposit was made: _____________________________

________________________________________________________

• Source of the funds in the account: ____________________________

________________________________________________________

• When you typically make deposits and withdrawals: _______________

________________________________________________________

   
18.

Do you or your spouse own a safe deposit box? If so:

• Name of bank and address of branch: _________________________

________________________________________________________

• Name(s) of holder of safe deposit box: _________________________

________________________________________________________

• Contents of box: __________________________________________

________________________________________________________

________________________________________________________

   
19.

Do you own any securities (that is, any document which grants a share of ownership in exchange for a loan or investment) such as bonds, annuities, etc? If so:

• Describe nature of security, bond, annuity, etc.: __________________

________________________________________________________

• Institution or person issuing it: _______________________________

________________________________________________________

• Approximate worth: $ ______________________________________

________________________________________________________

 

   
20.

Do you own any whole life insurance policies? If so:

• The name of the insurance company: __________________________

________________________________________________________

• The name of your insurance agent: ____________________________

________________________________________________________

• The face amount of the policy: $ ______________________________

________________________________________________________

• The cash value of the policy, if any: $ __________________________

________________________________________________________

   
21.

Do you own any of the following items? If so, describe the item, the item’s location, approximate value, and any joint owner:

• Office equipment: ________________________________________

________________________________________________________

• Gemstones, gems or jewelry: ________________________________

________________________________________________________

• Camera equipment: _______________________________________

________________________________________________________

• Computers: _____________________________________________

________________________________________________________

• Antiques: _______________________________________________

________________________________________________________

• Precious metals (gold, silver): _______________________________

________________________________________________________

• Musical instruments including pianos and organs: ________________

________________________________________________________

• Weapons (guns, swords, other): ______________________________

________________________________________________________

• Watches: _______________________________________________

________________________________________________________

• Stamp or coin collections: __________________________________

________________________________________________________

• China: _________________________________________________

________________________________________________________

• Original art works: ________________________________________

________________________________________________________

• Crystal: ________________________________________________

________________________________________________________

• Sports equipment, including exercise machines: _________________

________________________________________________________

• Stereo or musical equipment: _______________________________

________________________________________________________

• Any other items of value not mentioned above: ___________________

________________________________________________________

   
22.

Do you own, in your own name, or jointly with others, an automobile, truck, motorcycle, RV, motor home, mobile home, boat or plane? If so, provide the following information:

• Brief description (make, model and year): ______________________

________________________________________________________

• Approximate value: $ ______________________________________

________________________________________________________

• Legal owner: ____________________________________________

________________________________________________________

• Registered owner: ________________________________________

________________________________________________________

• License number: _________________________________________

________________________________________________________

• Vehicle identification number: _______________________________

________________________________________________________

• Amount owned, if any, to a legal owner: $ _______________________

________________________________________________________

• Any other lienholder you are aware of: _________________________

________________________________________________________

   
23.

Does a person, company or institution owe you money? If so:

• Name, address and telephone number of person or institution: _______

________________________________________________________

________________________________________________________

• Amount of each debt: $ ____________________________________

________________________________________________________

• How each debt arose (e.g., judgment, loan, inheritance): ___________

________________________________________________________

   
24.

Do you owe money to anyone else besides this current judgment where you have been sued and the other person or business has received a judgment? If so:

• To whom (address and telephone no.): _________________________

________________________________________________________

• Amount owed: $ __________________________________________

________________________________________________________

• Amount currently paid: $ ____________________________________

________________________________________________________

   
25.

Did you ever file for bankruptcy? If so:

• When: _________________________________________________

________________________________________________________

• Where (district and branch): _________________________________

________________________________________________________

• Type of bankruptcy (Chapter 7 or Chapter 13): ___________________

________________________________________________________

• Case number of the bankruptcy: ______________________________

________________________________________________________

   
26.

Are you a party (e.g., defendant or plaintiff) in any current action? This could be an action brought against you for a money judgment, an action in which you are the plaintiff, or any other action (including divorce, will contest, etc.)? If so:

• Who are the parties in each action: ___________________________

________________________________________________________

• Who are the attorneys in each action (names, addresses and phone numbers; include information for parties if they are appearing in pro per):

________________________________________________________

________________________________________________________

________________________________________________________

• A brief description of each lawsuit: ____________________________

________________________________________________________

________________________________________________________

• What is you position in the lawsuit, and do you expect to win: ________

________________________________________________________

   
27.

Does your wife or husband receive any salary, commissions, or other income, as an employee or independent contractor, from an employer or business? If so:

• Name, address and telephone number of employer: _______________

________________________________________________________

________________________________________________________

• Approximate amount and rate of income: $ _____________________

________________________________________________________


   
28.

Any other sources of income? If so:

• Amount of income: $ ______________________________________

________________________________________________________

• When do you receive income, and is it received on a regular basis: ___

________________________________________________________

________________________________________________________

• Brief description of source: _________________________________

________________________________________________________

   
29. Do you own any real estate individually or jointly (single family home, vacation home, co-op / condominium, duplex, rental property, business property, mobile home park, time share, undeveloped land, agricultural land, boat / marina dock space, airplane hangar, stationary mobile home)? If so:

• Address and country: ______________________________________

________________________________________________________

________________________________________________________

• Approximate fair market value: $ _____________________________

________________________________________________________

• Amount owed (first mortgage, second deed of trust):

1.

To whom: _______________________________________

_______________________________________________

_______________________________________________

   
2.

Amount and frequency of payments: ___________________

_______________________________________________

_______________________________________________

   

• When the property was obtained: ____________________________

_______________________________________________________

• What names are on the deed: _______________________________

_______________________________________________________

• Has title to the property been transferred since its acquisition by you: __

________________________________________________________

• Known debts or claims that affect the title (easements, tax liens, judgment liens, etc.): _______________________________________

________________________________________________________

________________________________________________________

• Approximate amount of your actual ownership (equity) in the property: $

________________________________________________________

• Does anyone live on the property: ____________________________

________________________________________________________

• Is the property developed, and if so, what kind of building(s): ________

________________________________________________________

   
30.

Are you a landlord? If so:

• Name and address of tenants: _______________________________

________________________________________________________

• Amount of rent paid and interval of payment: $ ___________________

________________________________________________________

   
31.

Do you rent where you are now living? If so:

• Amount of rent paid: $ _____________________________________

• Landlord’s name: _________________________________________

________________________________________________________

• Landlord’s address and phone number: ________________________

________________________________________________________

________________________________________________________

   
32.

Are you the trustee for, or beneficiary of, any property held in trust for yourself or a third person? If so:

• Briefly describe type of trust (e.g., living, bank account, spousal, Q-TIP):

________________________________________________________

• Identify whether you are the trustee or beneficiary, or both: __________

________________________________________________________

• Describe what the nature of the property s that is being held in trust (trust corpus): _____________________________________________

________________________________________________________

   
33.

Do you receive benefits from any government agency (e.g., unemployment insurance, disability insurance, workers compensation, social security, retirement, pension)? If so:

• Name of agency: _________________________________________

• Type of benefit: __________________________________________

• Amount of benefit: $ _______________________________________

• Frequency of benefit: ______________________________________

• The expected duration of the payments: ________________________

• Basis for the benefit (.e.g., unemployment, industrial injury, etc.): ______

________________________________________________________

   
34.

How much cash do you have on you right now: $ ___________________

________________________________________________________


 

 

 

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