Online Bankruptcy Questionnaire - The Law Office of Broc E. Whitehead

Bankruptcy Questionnaire

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Name of Debtor*
First Middle Last
Name of Co-debtor (Spouse)
First Middle Last
By completing this document and returning it to Broc E. Whitehead, I/we certify that it is my/our duty to disclose all assets, debts and other information, and that intentional concealment may constitute a crime. I/we understand that our attorney is relying on the complete accuracy of the information in this document to provide legal advice and prepare the bankruptcy lawsuit.
ANSWER EVERY QUESTION. ANY QUESTION LEFT BLANK WILL BE DEEMED A NO OR NONE ANSWER. IF YOU ARE UNCERTAIN ABOUT AN ANSWER, PUT A QUESTION MARK OR CALL OUR OFFICE.
SEND PHOTOCOPIES OF YOUR LATEST WAGE STATEMENTS UNTIL CASE IS FILED.
Debtor Social Security Number
Age
Co-Debtor social security number
Age
Clients authorize lawyer to communicate with them at the following e-mail address:*

Debtor address (including zip code):*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
County*
If you were a resident of a State other than Kansas in the last three years, state the dates of residency and the name of the state:
Debtor's home phone:
Debtor's work phone:
Debtor’s cell phone:
List all other names Debtor has used or has been known by in the past six years (such as maiden name, other married names, BUSINESS NAMES, etc.):
Co-debtor's home phone:
Co-debtor’s cell phone:
Co-Debtor's work phone
List all other names Co-Debtor has used or has been known by in the past six years (such as maiden name, other married names, BUSINESS NAMES, etc.):
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Circle one answer for each question:
Under what chapter is this bankruptcy:*
7
11
12
13
Debtor(s) is:
an individual and unmarried
an individual, married, and living apart
an individual, married, and living together
joint, married and living together
joint, married and living apart
If any of your debts were incurred as the result of operation of a business, state the name of the business, and if the business was officially incorporated, list the name of the state of incorporation.
Have you ever filed bankruptcy before?
Yes
No
If yes, when:

Bankruptcy Case No.:
Was a discharge granted:
When:

Do you owe any wages, salary, commissions, contribution to employee benefit plans, farmers, fishermen, deposits by individuals, TAXES or other debts to any governmental units, INCLUDING government insured student loans?
Be sure any such creditor is listed on one of the following pages. Do you have any secured debts such as vehicle loans or mortgages? State the amount of combined federal and state income tax refunds you anticipate receiving from taxes withheld from your wages during the current calendar year:
If you are entitled to receive more than $500.00 as an income tax refund, you may lose the refund to the bankruptcy court even if you receive the refund after you case is filed.
DEBTS OWED FOR TAXES, STUDENT LOANS AND WAGES: This section is used for listing the following debts: wages, salary, commissions, contribution to employee benefit plans, farmers, fishermen, deposits by individuals, TAXES or other debts to ANY governmental units, INCLUDING government insured student loans.
U.S. Treasury-IRS, Centralized Insolvency Operations, P.O. Box 21126, Philadelphia, PA 19114-0326.
Account number:
How much do you owe:
Date debt was incurred:

How much are your monthly payments:
Are they current:
If not, how many months behind are you:
If you owe a tax debt and have made an offer of compromise to the taxing authority, state the date:

Do you have notice of a tax lien?
Yes
No
Has this debt been turned over to a collection agency or an attorney:
Yes
No
If so:
Name of the Agency or Attorney
Address
Street Address Address Line 2 City State ZIP Code
Kansas Department of Revenue, Attn: CTE Bankruptcy Unit, P.O. Box 12005, Topeka, Kansas 66612-2005.
Account number:
How much do you owe:
Date debt was incurred:

What is debt for:
How much are your monthly payments:
Are they current:
If not, how many months behind are you:
If you owe a tax debt and have made an offer of compromise to the taxing authority, state the date:

Has this debt been turned over to a collection agency or an attorney:
Yes
No
If so: Name:
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Full name of Creditor:
Phone
Account number
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
How much do you owe:
Date debt was incurred:

What is debt for:
How much are your monthly payments:
Are they current:
Yes
No
If not, how many months behind are you:
If you owe a tax debt and have made an offer of compromise to the taxing authority, state the date:

Has this debt been turned over to a collection agency or an attorney:
Yes
No
If so: Name:
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Full name of Creditor:
Phone
Account number
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
How much do you owe:
Date debt was incurred:

What is debt for:
How much are your monthly payments:
Are they current:
Yes
No
If not, how many months behind are you:
If you owe a tax debt and have made an offer of compromise to the taxing authority, state the date:

Has this debt been turned over to a collection agency or an attorney:
Yes
No
If so: Name:
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Click the plus sign to add more creditors
Full name of Creditor: Phone Account number Creditor Address How much do you owe: Date debt was incurred: What is debt for: How much are your monthly payments: Are they current: If not, how many months behind are you: If you owe a tax debt and have made an offer of compromise to the taxing authority, state the date: Has this debt been turned over to a collection agency or an attorney: If so: Name and address

Click the plus sign to add more creditors
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III. SECURED DEBT LISTING SHEET
Review your billing statements closely and look for the creditor’s notice (usually on the back) indicating a special address only for bankruptcy notices.Failure to provide this address may limit. The effect of your bankruptcy on such creditor, so review you billing statements closely. SECURED CREDITORS
This section is used for listing secured debts, which are debts on which you have pledged collateral to the lender. All mortgages, loans secured by a lien on vehicles, furniture, appliances, etc. must be listed.
MORTGAGE LENDER:
Address
Street Address City State / Province / Region ZIP / Postal Code Country
Account number:
How much do you owe:
When did you take out the loan:

Is part of the home a
mobile home
manufactured home
modular home
If your home is on more than 1 acre, how many acres are there and are you inside a city?
If more than one acre, is your land divided by a river, government maintained road or other barrier?
Yes
No
What did you buy with the loan:
Have you owned your home for more than 3 years 4 months (40 months)?
When did you originally obtain the home:

Do you have more than 5 years (60 months) of payments remaining to be paid on the mortgage loan?
How much is each piece of secured property worth:
Do you want to keep the property or return it:
I want to keep the property
I want to return the property
How much are your monthly payments:
Are they current:
Yes
No
If not, how many months behind are you:
Has this debt been turned over to a collection agency or an attorney
Yes
No
If so: Name:
Address
Street Address City State / Province / Region ZIP / Postal Code Country
Did you use any funds from the sale of a residence outside the State of Kansas to purchase this residence?
Yes
No
FULL NAME OF CREDITOR:
Mailing address:
Street Address City State ZIP Code
Account number:
How much do you owe:
When did you take out the loan:

What did you buy with the loan:
When did you originally obtain the collateral property:

How much is each piece of secured property worth?
Do you want to keep the property or return it:
Yes
No
How much are your monthly payments:
Are they current:
Yes
No
If not, how many months behind are you
Has this debt been turned over to a collection agency or an attorney:
Yes
No
If so: Name:
Address
Street Address City State ZIP Code
Is a cosigner on the loan?
Yes
No
If so: Name:
Address
Street Address City State ZIP Code
FULL NAME OF CREDITOR:
Mailing address:
Street Address City State ZIP Code
Account number:
How much do you owe:
When did you take out the loan:

What did you buy with the loan:
When did you originally obtain the collateral property:

How much is each piece of secured property worth?
Do you want to
Keep the property
return the property
How much are your monthly payments:
Are they current:
If not, how many months behind are you:
Has this debt been turned over to a collection agency or an attorney
Yes
No
If so: Name:
Address
Street Address City State ZIP Code
Is a cosigner on the loan?
If so: Name:
Address
Street Address City State ZIP Code
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IV. DEBT LISTING SHEET
REVIEW YOUR BILLING STATEMENTS CLOSELY AND LOOK FOR THE CREDITOR’S NOTICE (USUALLY ON THE BACK) INDICATING A SPECIAL ADDRESS FOR CORRESPONDENCE OR BANKRUPTCY NOTICES. FAILURE TO PROVIDE THIS ADDRESS MAY LIMIT THE EFFECT OF YOUR BANKRUPTCY ON SUCH CREDITOR, SO REVIEW YOUR BILLING STATEMENTS CLOSELY.
NAME OF CREDITOR:
ACCOUNT NO
Address
Street Address City State ZIP Code
BALANCE OWED:
DATE INCURRED

REASON FOR DEBT:
If this debt has been turned over to a collection agency or attorney, complete this section: Name of agency/attorney:
Address
Street Address City State ZIP Code
NAME OF CREDITOR:
ACCOUNT NO
Address
Street Address City State ZIP Code
Account NO
DATE INCURRED:

REASON FOR DEBT
If this debt has been turned over to a collection agency or attorney, complete this section:
Name of agency/attorney:
Address
Street Address City State ZIP Code
NAME OF CREDITOR:
ACCOUNT NO
Address
Street Address City State ZIP Code
BALANCE OWED:
DATE INCURRED:

REASON FOR DEBT
If this debt has been turned over to a collection agency or attorney, complete this section:
Address
Street Address City State ZIP Code
Name of agency/attorney:
NAME OF CREDITOR:
ACCOUNT NO
Address
Street Address City State ZIP Code
BALANCE OWED:
DATE INCURRED:

REASON FOR DEBT
If this debt has been turned over to a collection agency or attorney, complete this section:
Name of agency/attorney:
Address
Street Address City State ZIP Code
NAME OF CREDITOR:
ACCOUNT NO
Address
Street Address City State ZIP Code
BALANCE OWED:
DATE INCURRED:

REASON FOR DEBT
If this debt has been turned over to a collection agency or attorney, complete this section:
Name of agency/attorney:
Address
Street Address City State ZIP Code
NAME OF CREDITOR:
ACCOUNT NO
Address
Street Address City State ZIP Code
BALANCE OWED:
DATE INCURRED:

REASON FOR DEBT
If this debt has been turned over to a collection agency or attorney, complete this section:
Name of agency/attorney:
Address
Street Address City State ZIP Code
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PERSONAL PROPERTY
You must list all of your property and assets below. Failure to list any property may prevent your attorney from protecting it from your creditors. If you are uncertain about whether certain property should be listed, you must list it so your attorney may determine how it will be treated by the bankruptcy court.
TYPE OF PROPERTY
DESCRIPTION AND LOCATION OF PROPERTY
HUSB. WIFE JOINT or COMM.
GARAGE SALE OR AUCTION VALUE
*
Cash on Hand DESCRIPTION AND LOCATION OF PROPERTY HUSB. WIFE JOINT or COMM. GARAGE SALE OR AUCTION VALUE

*
Checking, savings or other financial accounts, certificate of deposit, or shares in banks, savings and loan, thrift, building and loan, and homestead associations or credit unions, brokerage houses, or cooperatives. DESCRIPTION AND LOCATION OF PROPERTY HUSB. WIFE JOINT or COMM. GARAGE SALE OR AUCTION VALUE

Security deposits with public utilities, telephone companies, landlords, and others. DESCRIPTION AND LOCATION OF PROPERTY HUSB. WIFE JOINT or COMM. GARAGE SALE OR AUCTION VALUE

Household goods and furnishings, including audio, video, and computers DESCRIPTION AND LOCATION OF PROPERTY HUSB. WIFE JOINT or COMM. GARAGE SALE OR AUCTION VALUE

NO DETAILED LIST REQUIRED.
Books, pictures and other art objects, antiques, stamp, coin, record, tape, compact disc. And other collections or collectibles. DESCRIPTION AND LOCATION OF PROPERTY HUSB. WIFE JOINT or COMM. GARAGE SALE OR AUCTION VALUE

Wearing apparel DESCRIPTION AND LOCATION OF PROPERTY HUSB. WIFE JOINT or COMM. GARAGE SALE OR AUCTION VALUE

Furs and jewelry DESCRIPTION AND LOCATION OF PROPERTY HUSB. WIFE JOINT or COMM. GARAGE SALE OR AUCTION VALUE

Firearms and sports, photographic, and other hobby equipment. DESCRIPTION AND LOCATION OF PROPERTY HUSB. WIFE JOINT or COMM. GARAGE SALE OR AUCTION VALUE

Interests in insurance policies. Name insurance company of each policy and itemize surrender or refund value of each. DESCRIPTION AND LOCATION OF PROPERTY HUSB. WIFE JOINT or COMM. GARAGE SALE OR AUCTION VALUE

Annuities. issuer. DESCRIPTION AND LOCATION OF PROPERTY HUSB. WIFE JOINT or COMM. GARAGE SALE OR AUCTION VALUE

Itemize and name each
Interests in 401(k), IRA, ERICA, Keogh, or other pension or profit sharing plans. DESCRIPTION AND LOCATION OF PROPERTY HUSB. WIFE JOINT or COMM. GARAGE SALE OR AUCTION VALUE

Itemize
Stock and interests in incorporated and unincorporated businesses. DESCRIPTION AND LOCATION OF PROPERTY HUSB. WIFE JOINT or COMM. GARAGE SALE OR AUCTION VALUE

Itemize
Interests in partnerships or joint ventures. DESCRIPTION AND LOCATION OF PROPERTY HUSB. WIFE JOINT or COMM. GARAGE SALE OR AUCTION VALUE

Itemize
Government and corporate bonds and other negotiable and non-negotiable instruments. DESCRIPTION AND LOCATION OF PROPERTY HUSB. WIFE JOINT or COMM. GARAGE SALE OR AUCTION VALUE

Accounts Receivable. DESCRIPTION AND LOCATION OF PROPERTY HUSB. WIFE JOINT or COMM. GARAGE SALE OR AUCTION VALUE

Alimony, maintenance, support and property settlements to which the debtor is or may be entitled. DESCRIPTION AND LOCATION OF PROPERTY HUSB. WIFE JOINT or COMM. GARAGE SALE OR AUCTION VALUE

Give details.
Other liquidated debts owing debtor including tax refunds. DESCRIPTION AND LOCATION OF PROPERTY HUSB. WIFE JOINT or COMM. GARAGE SALE OR AUCTION VALUE

Give details.
Equitable or future interest, life estates, and rights or powers exercisable for the benefit of the debtor other than those listed in the Schedule of Real Property. DESCRIPTION AND LOCATION OF PROPERTY HUSB. WIFE JOINT or COMM. GARAGE SALE OR AUCTION VALUE

Contingent and non-contingent interest in estate of a decedent, death benefit plan, life insurance policy or trust. DESCRIPTION AND LOCATION OF PROPERTY HUSB. WIFE JOINT or COMM. GARAGE SALE OR AUCTION VALUE

Other contingent and unliquidated claims of any nature, including tax refunds, counterclaims of the debtor, and rights to set off claims. Give estimated value of each. DESCRIPTION AND LOCATION OF PROPERTY HUSB. WIFE JOINT or COMM. GARAGE SALE OR AUCTION VALUE

Give estimated value of each
Patents, copyrights, and other intellectual property DESCRIPTION AND LOCATION OF PROPERTY HUSB. WIFE JOINT or COMM. GARAGE SALE OR AUCTION VALUE

Give estimated value of each
Licenses, franchises and other general intangibles. Give particulars. DESCRIPTION AND LOCATION OF PROPERTY HUSB. WIFE JOINT or COMM. GARAGE SALE OR AUCTION VALUE

Give particulars.
Automobiles, trucks, trailers and other vehicles and accessories. DESCRIPTION AND LOCATION OF PROPERTY HUSB. WIFE JOINT or COMM. GARAGE SALE OR AUCTION VALUE

Boats, motors and accessories. DESCRIPTION AND LOCATION OF PROPERTY HUSB. WIFE JOINT or COMM. GARAGE SALE OR AUCTION VALUE

Aircraft and accessories. DESCRIPTION AND LOCATION OF PROPERTY HUSB. WIFE JOINT or COMM. GARAGE SALE OR AUCTION VALUE

Office equipment, furnishings and supplies. DESCRIPTION AND LOCATION OF PROPERTY HUSB. WIFE JOINT or COMM. GARAGE SALE OR AUCTION VALUE

Machinery, fixtures, equipment and supplies. DESCRIPTION AND LOCATION OF PROPERTY HUSB. WIFE JOINT or COMM. GARAGE SALE OR AUCTION VALUE

Inventory DESCRIPTION AND LOCATION OF PROPERTY HUSB. WIFE JOINT or COMM. GARAGE SALE OR AUCTION VALUE

Animals DESCRIPTION AND LOCATION OF PROPERTY HUSB. WIFE JOINT or COMM. GARAGE SALE OR AUCTION VALUE

Crops-growing or harvested DESCRIPTION AND LOCATION OF PROPERTY HUSB. WIFE JOINT or COMM. GARAGE SALE OR AUCTION VALUE

Give particulars.
Farming equipment and implements. DESCRIPTION AND LOCATION OF PROPERTY HUSB. WIFE JOINT or COMM. GARAGE SALE OR AUCTION VALUE

Give particulars.
Other personal property of any kind not already listed. DESCRIPTION AND LOCATION OF PROPERTY HUSB. WIFE JOINT or COMM. GARAGE SALE OR AUCTION VALUE

Give particulars.
List all interest in Real Estate (include location) DESCRIPTION AND LOCATION OF PROPERTY HUSB. WIFE JOINT or COMM. GARAGE SALE OR AUCTION VALUE

Give particulars.
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Section Break
List all addresses where you have resided during the last three years and for each address give the dates of occupancy:
Gross income received from employment, trade, profession or operation of business:
Debtor
Amount of income from January 1, to date:
source:
Income last year:
source:
Income prior year:
source
Co-Debtor:
Amount of income from January 1, to date:
source:
Income last year: $
source:
Income prior year: $
source:
List all other sources of income:
Has anyone sued you or have you divorced in the previous one year? If so: Who:
In what County and State:
Who:
In what county and state:
Has anyone attached, garnished, repossessed or seized any of your property: __________, If so: Who:
What did they take:
When did they take it:

What is its value:
Have you returned any property to anyone:
Yes
No
If so: Who:
What did you give them:
Date it was given:

What is its value:
List all payments adding up to more than $500.00 paid to any one creditor on loans, installment purchases of goods or services or any other debts within the last 90 days:_____ Name of Creditor:____ Date of Payment___ Amount of Payment
If you have taken cash advances of more than $750.00 within the last 70 days, state the name of the company, dates of cash advances and amounts:
Have you given anyone any gifts in the past year other than ordinary and usual presents:
Yes
No
If any banks or creditors have taken funds against a debt owed to such creditor, list the name of the creditor and the date of any such set off: __________________________________________________________________________
List all sales, gifts or other transfers of property with a value of more than $300.00 made to any person or business during the last two years (name and address of purchaser):
If you have lived in a community property state with a spouse or ex-spouse within the last 8 years, including the States of AK, AZ, CA, ID, LA, NV,within the last 8 years, provide the name and current address of such spouse.
If you have suffered any losses from fire, theft or gambling during the last year, state the type of loss, the amount and the date the loss occurred:
Was the loss covered in whole or in part by insurance:
List all payments made or property transferred to an attorney or anyone else for bankruptcy services or debt consolidation:
List any checking or savings accounts you have closed in the last year:
Name of bank:_________________________________Type of Account _____________ Address: __________________________________________________________________ Account number: _____________________________ Account balance: $___________
List any safe deposit boxes or other depositories you have maintained in the last 2 years:
Name and address of bank:
Are you holding any property that belongs to someone else
Yes
No
If so: Who are you holding it for:
Address:
What are you holding:
What is its value: $
Relationship to property owner:
Why are you holding it:
Is anyone holding any of your property:
If so: Who is holding it?
Address:
What are they holding:
What is its value:
Why are they holding it:
If you have made purchases of more than $1,000.00 on any credit card within the last 60 days or taken cash advances totaling more than $1,000.00 within the last 60 days, list the name of the credit card company and the date(s) of any such transactions:
If you have borrowed any money within the last 90 days, please state the name of the lender, describe any property pledged as collateral and briefly give the circumstances surrounding the loan________________________________
Name of the card and the amount paid?
Yes
No
If so, what was the name of the card and the amount paid?
If you have repaid a loan or debt owed to a relative, family member or close friend within the last 12 months state the amount paid, date, name and relationship:
Have you or any member of your family suffered a personal injury or have any other legal claims against an insurance company or someone else on which you expect to recover money?
Yes
No
If so, please provide the details:
If you have pledged household goods, like televisions, stereos, etc. or other personal property as security on a debt, please state the name of the creditor and the specific property. ___________________
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CURRENT INCOME AND CURRENT EXPENSES
Gross wages per pay period (select one):
How often is debtor paid:
How often is co-debtor paid:
Debtor's current employment:
Employer's name:
Employer's Address:
Employer's phone:
Length of Employment:
Position with employer:
Are self employed or in business:
If so, in what business are you engaged:
Co-Debtor's current employment:
Employer's name:
Employer's address:
Employer's phone:
Length of Employment:
Position with employer:
Are self employed or in business:
If so, in what business are you engaged:
List dates over the next 60 days when debtor and Co-debtor will receive paychecks:
Debtor:
Co-Debtor:
*PLEASE PROVIDE COPY OF PAY STATEMENT
GROSS MONTHLY INCOME
Debtor's monthly income Co-debtor's monthly income

AVERAGE OVERTIME
Debtor's average overtime co-debtor's average overtime

Deductions: Taxes (Federal, Social Security, State)
Debtor's s deductions co-debtor's deductions

INSURANCE
Debtor's s Insurance Co-debtor's Insurance

Union Dues
Debtor's s Union Dues Co-debtor's Union Dues

OTHERS
Debtor Co-debtor

OTHERS
Debtor Co-debtor

OTHERS
Debtor Co-debtor

Other income per month:
If self-employed, regular income Income from real estate Interest and dividends Social security or other government assistance:
Debtor Co-debtor

Child Support received:
Yes
No
Pension or retirement income Spousal support received
Debtor Co-debtor

If received child support
Child's name Age Relationship Amount

TOTAL MONTHLY INCOME:
DEBTOR TOTAL MONTHLY INCOME CO-DEBTOR TOTAL MONTHLY INCOME

Describe any expected changes in income or deductions:
CURRENT EXPENSES
List all dependents whose expenses you pay (do not include yourself or co-debtor):
Name Age Relationship

Monthly expenses:
Rent/Mortgage payment
Are property taxes included?
Yes
No
Electricity and heating fuel
Water and sewer
Home telephone
Caller I.D.
Call waiting
Long distance
Cell phone
Internet service
Cable television
Pager
*(Even if paid with other services, break out each monthly cost.)
Garbage
Security
Other utilities
Home maintenance
Food
Clothing
Laundry/dry cleaning
Medical/Dental
Transportation (include gas and auto repairs )
Recreation/clubs/entertainment
Newspapers/periodicals/books
Charitable contributions.
Homeowner's/renter's insurance
Life insurance
Health insurance
Auto insurance
Other insurance
Other insurance
Other insurance
Other insurance
Real estate and personal property taxes.
Other taxes
Auto installment payments
Other installment payments
Other installment payments
Child care
Child support paid
Name: Age: Relationship:

Child support paid
Payments for dependents not living at home Other expenses not previously listed:
School activities and expenses
Household items
Personal hygiene
TOTAL MONTHLY EXPENSES
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DOMESTIC SUPPORT OBLIGATIONS
SUPPORT YOU PAY:
Fully disclose any parent’s name and addressfor all child and spousal support obligations that you are obligated to pay, even if the payments are current. Do not use the court address:
Name:
Address:
Amount per month:
Name:
Address:
Amount per month:
SUPPORT PAID TO YOU:
Fully disclose the name and address of any parent that pays child support or spousal support to you:
Name:
Address:
Amount per month:
Name:
Address:
Amount per month:
BROC E. WHITEHEAD BANKRUPTCY
SERVICES OF KANSAS
310 WEST CENTRAL, SUITE 104
WICHITA, KANSAS 67202
BROC E. WHITEHEAD
ATTORNEY AT LAW
TELEPHONE: (316) 263-6500
FACSIMILE: (316) 263-6254
BANKRUPTCY INFORMATION BROCHURE
BANKRUPTCY SERVICES OF KANSAS If you choose to employ Bankruptcy Services of Kansas to represent you in commencing a bankruptcy action, you will be represented by Broc E. Whitehead. Mr. Whitehead is a member of the Kansas Bar Association with over 25 years experience representing individuals and businesses in bankruptcy proceedings. Mr. Whitehead received his law degree from Washburn School of Law in Topeka, Kansas and is a member of the Bankruptcy Law Section of the Kansas Bar Association.
Bankruptcy Services of Kansas is designed to provide quality bankruptcy representation at affordable rates. Bankruptcy Services of Kansas is located two blocks from the federal bankruptcy court in Wichita, Kansas, which is the court where individuals and businesses located in Central, Southern and Western Kansas must file their bankruptcy actions.
If you employ Bankruptcy Services of Kansas to represent you in commencing a bankruptcy action, all communications with your attorney are kept in strict confidence and will not be disclosed to anyone beyond the information required by the federal bankruptcy court.
TYPES OF BANKRUPTCY PROCEEDINGS
CHAPTER 7 - LIQUIDATION
A Chapter 7 or liquidation bankruptcy procedure is the most common type of bankruptcy action filed by individuals. This procedure allows individuals to discharge all debts, except debts for income taxes, alimony, child support, student loans and several others. Discharge of a debt in bankruptcy proceedings means that you are no longer obligated to pay the debt and the individual or business to whom the debt is owed may no longer attempt to collect the debt from you.
CHAPTER 13 - WAGE EARNER
This procedure allows you to reduce the amount of monthly payments you pay to your creditors by presenting a plan to the bankruptcy court scheduling a single payment made to the bankruptcy trustee each month over a period of 3 to 5 years. From your monthly payment, the bankruptcy trustee pays your creditors.
CHAPTER 11 - REORGANIZATION
An individual or business may elect a reorganization proceeding in which a plan is presented for approval by the bankruptcy court for payment of all or a portion of the outstanding debts over a period of time; the amount of the payments may differ from the original payment terms with the creditors.
CHAPTER 12 - FAMILY FARM REORGANIZATION
For certain types of family farm operations, a special bankruptcy procedure is available which allows the continuation of regular farming operations while a reorganization plan is submitted to the bankruptcy court.
REQUIRED NOTICE
A person who knowingly and fraudulently conceals assets or makes a false oath or statement under penalty of perjury in connection with a bankruptcy case shall be subject to fine, imprisonment or both. All information supplied by a debtor in connection with a case under the bankruptcy code is subject to examination by the Attorney General.
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Full name of Creditor:	Phone	Account number	Creditor Address	How much do you owe:	Date debt was incurred:	What is debt for:	How much are your monthly payments:	Are they current:	If not, how many months behind are you:	If you owe a tax debt and have made an offer of compromise to the taxing authority, state the date:	Has this debt been turned over to a collection agency or an attorney:	If so: Name and address

Cash on Hand	DESCRIPTION AND LOCATION OF PROPERTY	HUSB. WIFE JOINT or COMM.	GARAGE SALE OR AUCTION VALUE

Checking, savings or other financial accounts, certificate of deposit, or shares in banks, savings and loan, thrift, building and loan, and homestead associations or credit unions, brokerage houses, or cooperatives.	DESCRIPTION AND LOCATION OF PROPERTY	HUSB. WIFE JOINT or COMM.	GARAGE SALE OR AUCTION VALUE

Security deposits with public utilities, telephone companies, landlords, and others.	DESCRIPTION AND LOCATION OF PROPERTY	HUSB. WIFE JOINT or COMM.	GARAGE SALE OR AUCTION VALUE

Household goods and furnishings, including audio, video, and computers	DESCRIPTION AND LOCATION OF PROPERTY	HUSB. WIFE JOINT or COMM.	GARAGE SALE OR AUCTION VALUE

Books, pictures and other art objects, antiques, stamp, coin, record, tape, compact disc. And other collections or collectibles.	DESCRIPTION AND LOCATION OF PROPERTY	HUSB. WIFE JOINT or COMM.	GARAGE SALE OR AUCTION VALUE

Wearing apparel	DESCRIPTION AND LOCATION OF PROPERTY	HUSB. WIFE JOINT or COMM.	GARAGE SALE OR AUCTION VALUE

Furs and jewelry	DESCRIPTION AND LOCATION OF PROPERTY	HUSB. WIFE JOINT or COMM.	GARAGE SALE OR AUCTION VALUE

Firearms and sports, photographic, and other hobby equipment.	DESCRIPTION AND LOCATION OF PROPERTY	HUSB. WIFE JOINT or COMM.	GARAGE SALE OR AUCTION VALUE

Interests in insurance policies. Name insurance company of each policy and itemize surrender or refund value of each.	DESCRIPTION AND LOCATION OF PROPERTY	HUSB. WIFE JOINT or COMM.	GARAGE SALE OR AUCTION VALUE

Annuities. issuer.	DESCRIPTION AND LOCATION OF PROPERTY	HUSB. WIFE JOINT or COMM.	GARAGE SALE OR AUCTION VALUE

Interests in 401(k), IRA, ERICA, Keogh, or other pension or profit sharing plans.	DESCRIPTION AND LOCATION OF PROPERTY	HUSB. WIFE JOINT or COMM.	GARAGE SALE OR AUCTION VALUE

Stock and interests in incorporated and unincorporated businesses.	DESCRIPTION AND LOCATION OF PROPERTY	HUSB. WIFE JOINT or COMM.	GARAGE SALE OR AUCTION VALUE

Interests in partnerships or joint ventures.	DESCRIPTION AND LOCATION OF PROPERTY	HUSB. WIFE JOINT or COMM.	GARAGE SALE OR AUCTION VALUE

Government and corporate bonds and other negotiable and non-negotiable instruments.	DESCRIPTION AND LOCATION OF PROPERTY	HUSB. WIFE JOINT or COMM.	GARAGE SALE OR AUCTION VALUE

Accounts Receivable.	DESCRIPTION AND LOCATION OF PROPERTY	HUSB. WIFE JOINT or COMM.	GARAGE SALE OR AUCTION VALUE

Alimony, maintenance, support and property settlements to which the debtor is or may be entitled.	DESCRIPTION AND LOCATION OF PROPERTY	HUSB. WIFE JOINT or COMM.	GARAGE SALE OR AUCTION VALUE

Other liquidated debts owing debtor including tax refunds.	DESCRIPTION AND LOCATION OF PROPERTY	HUSB. WIFE JOINT or COMM.	GARAGE SALE OR AUCTION VALUE

Equitable or future interest, life estates, and rights or powers exercisable for the benefit of the debtor other than those listed in the Schedule of Real Property.	DESCRIPTION AND LOCATION OF PROPERTY	HUSB. WIFE JOINT or COMM.	GARAGE SALE OR AUCTION VALUE

Contingent and non-contingent interest in estate of a decedent, death benefit plan, life insurance policy or trust.	DESCRIPTION AND LOCATION OF PROPERTY	HUSB. WIFE JOINT or COMM.	GARAGE SALE OR AUCTION VALUE

Bankruptcy Questionnaire

Step 1 of 8

Circle one answer for each question:

U.S. Treasury-IRS, Centralized Insolvency Operations, P.O. Box 21126, Philadelphia, PA 19114-0326.

If so:

Kansas Department of Revenue, Attn: CTE Bankruptcy Unit, P.O. Box 12005, Topeka, Kansas 66612-2005.

III. SECURED DEBT LISTING SHEET

This section is used for listing secured debts, which are debts on which you have pledged collateral to the lender. All mortgages, loans secured by a lien on vehicles, furniture, appliances, etc. must be listed.

IV. DEBT LISTING SHEET

If this debt has been turned over to a collection agency or attorney, complete this section:

If this debt has been turned over to a collection agency or attorney, complete this section:

If this debt has been turned over to a collection agency or attorney, complete this section:

If this debt has been turned over to a collection agency or attorney, complete this section:

If this debt has been turned over to a collection agency or attorney, complete this section:

PERSONAL PROPERTY

TYPE OF PROPERTY

DESCRIPTION AND LOCATION OF PROPERTY

HUSB. WIFE JOINT or COMM.

GARAGE SALE OR AUCTION VALUE

Section Break

Gross income received from employment, trade, profession or operation of business:

Debtor

Co-Debtor:

CURRENT INCOME AND CURRENT EXPENSES

Gross wages per pay period (select one):

Debtor's current employment:

Co-Debtor's current employment:

List dates over the next 60 days when debtor and Co-debtor will receive paychecks:

*PLEASE PROVIDE COPY OF PAY STATEMENT

Other income per month:

CURRENT EXPENSES

Monthly expenses:

*(Even if paid with other services, break out each monthly cost.)

DOMESTIC SUPPORT OBLIGATIONS

SUPPORT YOU PAY:

Fully disclose any parent’s name and addressfor all child and spousal support obligations that you are obligated to pay, even if the payments are current. Do not use the court address:

SUPPORT PAID TO YOU:

Fully disclose the name and address of any parent that pays child support or spousal support to you:

BROC E. WHITEHEAD BANKRUPTCY SERVICES OF KANSAS

310 WEST CENTRAL, SUITE 104 WICHITA, KANSAS 67202

BROC E. WHITEHEAD ATTORNEY AT LAW

TELEPHONE: (316) 263-6500 FACSIMILE: (316) 263-6254

BANKRUPTCY INFORMATION BROCHURE

TYPES OF BANKRUPTCY PROCEEDINGS

CHAPTER 7 - LIQUIDATION

CHAPTER 13 - WAGE EARNER

CHAPTER 11 - REORGANIZATION

CHAPTER 12 - FAMILY FARM REORGANIZATION

REQUIRED NOTICE

BROC E. WHITEHEAD BANKRUPTCY
SERVICES OF KANSAS

310 WEST CENTRAL, SUITE 104
WICHITA, KANSAS 67202

BROC E. WHITEHEAD
ATTORNEY AT LAW

TELEPHONE: (316) 263-6500
FACSIMILE: (316) 263-6254

Other contingent and unliquidated claims of any nature, including tax refunds, counterclaims of the debtor, and rights to set off claims. Give estimated value of each.	DESCRIPTION AND LOCATION OF PROPERTY	HUSB. WIFE JOINT or COMM.	GARAGE SALE OR AUCTION VALUE

Patents, copyrights, and other intellectual property	DESCRIPTION AND LOCATION OF PROPERTY	HUSB. WIFE JOINT or COMM.	GARAGE SALE OR AUCTION VALUE

Licenses, franchises and other general intangibles. Give particulars.	DESCRIPTION AND LOCATION OF PROPERTY	HUSB. WIFE JOINT or COMM.	GARAGE SALE OR AUCTION VALUE

Automobiles, trucks, trailers and other vehicles and accessories.	DESCRIPTION AND LOCATION OF PROPERTY	HUSB. WIFE JOINT or COMM.	GARAGE SALE OR AUCTION VALUE

Boats, motors and accessories.	DESCRIPTION AND LOCATION OF PROPERTY	HUSB. WIFE JOINT or COMM.	GARAGE SALE OR AUCTION VALUE

Aircraft and accessories.	DESCRIPTION AND LOCATION OF PROPERTY	HUSB. WIFE JOINT or COMM.	GARAGE SALE OR AUCTION VALUE

Office equipment, furnishings and supplies.	DESCRIPTION AND LOCATION OF PROPERTY	HUSB. WIFE JOINT or COMM.	GARAGE SALE OR AUCTION VALUE

Machinery, fixtures, equipment and supplies.	DESCRIPTION AND LOCATION OF PROPERTY	HUSB. WIFE JOINT or COMM.	GARAGE SALE OR AUCTION VALUE

Inventory	DESCRIPTION AND LOCATION OF PROPERTY	HUSB. WIFE JOINT or COMM.	GARAGE SALE OR AUCTION VALUE

Animals	DESCRIPTION AND LOCATION OF PROPERTY	HUSB. WIFE JOINT or COMM.	GARAGE SALE OR AUCTION VALUE