Is there a pending sale date for your home or other real property?
 Yes No

If yes, what is the date of that sale?

Chapter 7?
 Yes No

Chapter 13?
 Yes No

Last Name

First Name

Middle Name

Telephone Number (Home)

Telephone Number (Work)

Have you used any other names in the past eight years?
 Yes No

If yes, list other names

Social Security Number

Address

City

State

Zip

County

Have you lived at this address for at least 180 days?
 Yes No

Have you lived at this address for at least 730 days (2 years)?
 Yes No

If you answered no to either of the questions above, please list your previous address

Address

City

State

Zip

County

If you have a different mailing address, please list

Address

City

State

Zip

If you are filing jointly with your spouse, fill in the following information about your spouse

Last Name

First Name

Middle Name

Has your spouse used any other names in the past eight years?
 Yes No

If yes, list other names

Social Security Number

Address (if different from your address)

City

State

Zip

County

If your spouse has a different mailing address, please list

Address

City

State

Zip

Has a bankruptcy case been filed by you or against you in the last 8 years?
 Yes No

If yes, in which district of which state was the case filed?

Case Number

Date filed

Are there currently any bankruptcy cases pending against you, your business, your spouse, or your spouse's business?
 Yes No

If yes, name of debtor

Relationship to you

Case Number

Date filed

Judge

In which district of which state was the case filed?

Exhibit "C" to the Voluntary Petition

Do you own or have possession of any property that poses or a threat of imminent and identifiable harm to public health or safety?
 Yes No

(If yes, please attach a list and description of the property.)

Debtors Who Reside as Tenants of Residential Property

If you rent your home, does a landlord hold a judgment against you?
 Yes No

If yes, please provide the name and address of the landlord

Name

Address

City

State

Zip

Part A. Real Estate (Schedule A)

List all real estate which you own or are a joint owner of, even if you still owe money on the property.

Part B. Personal Property (Schedule B)

For each type of property listed below, indicate whether you own any property of that category, and, if you do, fill in the remaining information. You can think of the value as the replacement value. For property acquired for personal or family use, replacement value is the price a retail merchant would charge for a property of that kind, considering the age and condition of that property.

List below all debts that you owe, or that creditors claim that you owe.

List below any leases or contracts that are still current that you are a party to. Include residential, car and business leases, and service or business contracts.

Marital Status
MarriedSingleDivorcedSeparatedWidowed

List all dependents of you and your spouse, their ages, and their relationship to you:

What is your occupation?

Name and address of your employer

How long have you been employed there?

What is the gross amount of your paycheck, before taxes/other deductions are taken out? $

How often do you get paid?
once a weekevery two weekstwice a monthonce a month

other

Complete the below questions with your estimate of monthly averages.

Do you receive overtime pay outside of your salary? If so, how much per month? $

How much is taken out of each paycheck for taxes and social security? $

How much is taken out for insurance? $

How much for union dues? $

Are there other deductions? If so, what are they and how much?

Do you receive

• income from business operations outside of your regular paycheck listed above? If so, what is the business and how much do you receive per month? $

What is your occupation?

Name and address of your employer

How long have you been employed there?

What is the gross amount of your paycheck, before taxes/other deductions are taken out? $

How often do you get paid?
once a weekevery two weekstwice a monthonce a month

other

Complete the below questions with your estimate of monthly averages.

Do you receive overtime pay outside of your salary? If so, how much per month? $

How much is taken out of each paycheck for taxes and social security? $

How much is taken out for insurance? $

How much for union dues? $

Are there other deductions? If so, what are they and how much?

Do you receive

• income from business operations outside of your regular paycheck listed above? If so, what is the business and how much do you receive per month?

  Are you or your spouse expecting any increase or decrease in salary next year? If so, explain.
  
  

Fill in your monthly income for the categories below in the column labeled "Month 1." If your income for one of the below categories varies from month to month, complete the below chart by entering in your income for all six months.

Do you and your spouse maintain separate households?
 Yes No

If so, fill one page out for your household and another for your spouse's.

The following questions ask for your expenses each month. If you are unsure of the amount you pay each month, but know the amount for a different period (per week, per day, every 2 months, etc.,), write in the amount and the frequency that you pay the amount.

Indicate how much you pay for each item each month...

your rent or your home mortgage $

Does that amount include real estate taxes?
 Yes No

Does it include property insurance?
 Yes No

electricity and heating $

water and sewage $

telephone service/long distance $

Do you have any other utility bills? If so, what, and how much per month?

home maintenance, including repairs and general upkeep $

food $

clothing $

laundry and dry cleaning $

medical and dental expenses $

transportation (not including car payments) $

entertainment, recreation, newspapers, magazines $

charitable contributions $

insurance not deducted from paycheck

• homeowner's or renter's insurance $

  taxes not deducted from paycheck $

  installment payments for car, furniture, etc. (Specify)
  
  

  alimony, maintenance, support paid to others $

  payments for support of dependents not living at home $

  expenses from operation of business $

  Additional Expenses (707(b) Expenses)

  mandatory payroll deductions not already listed
  
  

  court ordered payments not already listed
  
  

  education necessary to maintain employment $

  education for a physically or mentally challenged child $

  childcare $

  disability insurance (if not listed on line 14) $

  health savings accounts $

  care for elderly, chronically ill, or disabled family members $

  protection from family violence $

  education expense for your children under 18 $

  non-mandatory contributions to retirement accounts (including loan repayment)
  
  

  other expenses not listed above
  
  

If you are filing jointly with your spouse, include information about both you and your spouse. If you are filing under chapter 12 or 13, and you are married and not separated, you must provide information about your spouse even if you are not filing jointly.

If you have no information to report for a question, check the "NONE" box.

1. Income from employment or operation of business

   State your gross income from employment or operation of a business: If you have not received an income from employment during the two years immediately preceding this calendar year, check this box:

    None

   Period	$ Amount	Source	Husband/Wife
   January 1 of this year through date of commencement of case
   Last year, (January 1 - December 31)
   The year before last, (January 1 - December 31)

2. Income other than from employment or operation of business

   State the amount of income received other than from employment or operation of business during the two years immediately preceding the commencement of this case:

    None

   Period	$ Amount	Source	Husband/Wife
   During the last year
   Year before last

3. Payments to creditors

   1. If your debts are primarily consumer debts, list all payments on loans, installment purchases of goods or services, and other debts, aggregating more than $600 to any creditor made within 90 days immediately preceding the commencement of this case. Indicate with an asterisk (*) any payments that were made on account of a domestic support obligation, or that were made as part of an alternative repayment plan.

       None

      Name and Address of Creditor	Dates of Payments	Amount paid	Amount still owed

   2. If your debts are not primarily consumer debts, list each payment or other transfer, aggregating more than $5,475 to any creditor made within 90 days immediately preceding the commencement of this case.

       None

      Name and Address of Creditor	Dates of Payments	Amount paid	Amount still owed

   3. All debtors. List all payments made within one year immediately preceding the commencement of this case to or for the benefit of creditors who are or were "insiders". ("Insiders" include your relatives, your business partners and their relatives, your corporations, or your affiliates.)

       None

      Name and Address of Creditor	Dates of Payments	Amount paid	Amount still owed

4. Suits, executions, garnishments and attachments

   1. List all suits and administrative proceedings to which you are or were a party within one year preceding the filing of this case.

       None

      Caption of Suit and Case Number	Nature of Proceeding	Court or Agency and Location	Status or Disposition

   2. Describe all property that has been garnished, seized, or attached under any legal or equitable process within one year immediately preceding the commencement of this case.

       None

      Name and Address of Person/Company Description for Whom the Property Was Seized (Creditor)	Date of Seizure	Description and Value of Property

5. Repossessions, foreclosures, and returns

   List all property that has been repossessed by a creditor, sold at a foreclosure sale, transferred through a deed in lieu of foreclosure, or returned to the seller, within one year immediately preceding the commencement of this case.

    None

   Name and Address of Creditor	Date of Repossession, Foreclosure, Transfer or Return	Description and Value of Property

6. Assignments and receiverships

   1. Describe any assignment of property for the benefit of creditors made within 120 days immediately preceding the commencement of this case.

       None

      Name and Address of Assignee	Date of Assignment	Terms of Assignment/Settlement

   2. List all property which has been in the hands of a custodian, receiver, or court-appointed official within one year immediately preceding the commencement of this case.

       None

      Name and Address of Custodian	Name and location of Court, Case Title and Number	Date of Order	Description and Value of Property

7. Gifts

   List all gifts or charitable contributions made within one year immediately preceding the commencement of this case except ordinary and usual gifts to family members aggregating less than $200 in value per individual family member and charitable contributions aggregating less than $100 per recipient.

    None

   Name and Address of Recipient	Relationship to You, if Any	Date of Gift	Description and Value of Gift

8. Losses

   List all losses from fire, theft, gambling or other casualty within one year immediately preceding thecommencement of this case or since the commencement of this case.

    None

   Description and Value of Property	Description of Circumstances and Amount Covered by Insurance, if Any	Date of Loss

9. Payments related to debt counseling or bankruptcy

   List all payments made or property transferred by or on behalf of the debtor to any persons, including attorneys, for consultation concerning debt consultation, relief under the bankruptcy law or preparation of the petition in bankruptcy within one year immediately preceding the commencement of the case.

    None

   Name and Address of Payee	Date of Payment	Name of Person Who Paid, if Not You	Amount of Money/ Description and Value of Property

10. Other transfers (including sale of your property)

    1. List all other property, other than property transferred in your ordinary course of business or financial affairs, transferred either absolutely or as a security within two years immediately preceding the commencement of this case.

        None

       Name and Address of Transferee and Relationship to you	Date of Transfer	Description of Property Transferred and Value Received

    2. List all property you transferred within 10 years immediately preceding the commencement of this case to a self-settled trust, or a similar device of which you are the beneficiary.

        None

       Name of Trust or Similar Device	Date of Transfer	Amount of Money or Description and Value of Property or Interest

11. Closed financial accounts

    List all financial accounts and instruments held in your name or for your benefit which were closed, sold, or otherwise transferred within one year immediately preceding the commencement of this case.

     None

    Name and Address of Institution	Type and Number of Account & Final Balance	Amount and Date of Sale or Closing

12. Safe deposit boxes

    List each safe deposit or other box or depository in which you have or have had securities, cash, or other valuables within one year immediately preceding commencement of this case.

     None

    Name and Address of Bank or Other Depository	Name and Address of Those With Access to Box or Depository	Description of Contents	Date of Transfer, if Any

13. Setoffs

    List all setoffs made by any creditor, including a bank, against a debt or deposit of yours within 90 days preceding the commencement of this case.

     None

    Name and Address of Creditor	Date of Setoff	Amount of Setoff

14. Property held for another person

    List all property that you hold or control that is owned by another person.

     None

    Name and Address of Owner	Description and Value of Property	Location of Property

15. Prior address of debtor

    If you have moved within the three years immediately preceding the commencement of this case, list all residences during the last three years, excluding your present address.

     None

    Address	Your Name at the Time	Dates of Occupancy

16. Spouses and Former Spouses

    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 eight-year period immediately preceding the commencement of the case, identify the name of your spouse and of any former spouse who resides or resided with you in the community property state.

     None

    Name(s)
    
    

17. Environmental Information.

    For the purpose of this question, the following definitions apply:

    "Environmental Law" means any federal, state, or local statute or regulation regulating pollution, contamination, releases of hazardous or toxic substances, wastes or material into the air, land, soil, surface water, groundwater, or other medium, including, but not limited to, statutes or regulations regulating the cleanup of these substances, wastes, or material.

    "Site" means any location, facility, or property as defined under any Environmental Law, whether or not presently or formerly owned or operated by the debtor, including, but not limited to, disposal sites. "Hazardous Material" means anything defined as a hazardous waste, hazardous substance, toxic substance, hazardous material, pollutant, or contaminant or similar term under an Environmental Law

    1. List the name and address of every site for which you received notice in writing by a governmental unit that it may be liable or potentially liable under or in violation of an Environmental Law. Indicate the governmental unit, the date of the notice, and, if known, the Environmental Law:

        None

       Site Name and Address	Name and Address of Governmental Unit	Date of Notice	Environmental Law

    2. List the name and address of every site for which you provided notice to a governmental unit of a release of Hazardous Material. Indicate the governmental unit to which the notice was sent and the date of the notice.

        None

       Site Name and Address	Name and Address of Governmental Unit	Date of Notice	Environmental Law

    3. List all judicial or administrative proceedings, including settlements or orders, under any Environmental Law with respect to which you are or were a party. Indicate the name and address of the governmental unit that is or was a party to the proceeding, and the docket number.

        None

       Name and Address of Governmental Unit	Docket Number	Status or Disposition

18. Nature, location and name of business

    1. If the debtor is an individual, list the names, addresses, taxpayer identification numbers, nature of the businesses, and beginning and ending dates of all businesses in which the debtor was an officer, director, partner, or managing executive of a corporation, partnership, sole proprietorship, or was a self-employed professional within the six years immediately preceding the commencement of this case, or in which the debtor owned 5 percent or more of the voting or equity securities within the six years immediately preceding the commencement of this case.

       If the debtor is a partnership, list the names, addresses, taxpayer identification numbers, nature of the businesses, and beginning and ending dates of all businesses in which the debtor was a partner or owned 5 percent or more of the voting or equity securities, within the six years immediately preceding the commencement of this case.

       If the debtor is a corporation, list the names, addresses, taxpayer identification numbers, nature of the businesses, and beginning and ending dates of all businesses in which the debtor was a partner or owned 5 percent or more of the voting or equity securities within the six years immediately preceding the commencement of this case.

        None

       Name	Taxpayer I.D. Number(EIN)	Address	Nature of Business	Beginning and End Dates of Operation

    2. Identify any business listed in response to subdivision a., above, that is "single asset real estate" as defined in 11 U.S.C. � 101.

        None

       Name	Address

    The following questions, #19-25, are only to be answered if you are a corporation or partnership or if you have been, in the six years immediately preceding this case, an officer, director, managing executive, or owner of more than 5% of the voting securities of the corporation; a partner, other than a limited partner, of a partnership; a sole proprietor, or otherwise self-employed.

19. Books, records, and financial statements

    1. List all bookkeepers and accountants who, within the two years immediately preceding the filing of this bankruptcy case, kept or supervised the keeping of books of account and records.

        None

       Name	Address	Dates Services Rendered

    2. List all firms or individuals who, within the two years immediately preceding the filing of this bankruptcy case, have audited the books of account and records, or prepared a financial statement of the debtor.

        None

       Name	Address	Dates Services Rendered

    3. List all firms or individuals who, at the time of the commencement of this case, were in possession of your books of account and records. If the records are not available, explain.

        None

       Name	Address	Comments

    4. List all financial institutions, creditors and other parties, including mercantile and trade agencies, to whom a financial statement was issued by the debtor within two years immediately preceding the commencement of this case.

        None

       Name	Address	Date Issued

20. Inventories

    1. List the dates of the last two inventories taken of your property, the name of the person who supervised the taking of each inventory, and the dollar amount and basis of each inventory.

        None

       Date of Inventory	Inventory Supervisor	Dollar Amount of Inventory (specify cost, market, or other basis)

    2. List the name and address of the person possessing the records of each of the two inventories reported in a.) above.

        None

       Date of Inventory	Name and Address of Custodian of Inventory Records

21. Current partners, officers, directors, and shareholders

    1. If your business is a partnership, list the nature and percentage of partnership interest of each member of the partnership.

        None

       Name and Address	Nature of Interest	Percentage of Interest

    2. If your business is a corporation, list all officers and directors of the corporation, and each stockholder who directly or indirectly owns, controls, or holds 5 % or more of the voting securities of the corporation.

        None

       Name and Address	Title	Nature and Percentage of Stock Ownership

22. Former partners, officers, directors and shareholders

    1. If your business is a partnership, list each member who withdrew from the partnership within one year immediately preceding the commencement of this case.

        None

       Name	Address	Date of Withdrawal

    2. If your business is a corporation, list all officers or directors whose relationship with the corporation terminated within one year immediately preceding the commencement of this case.

        None

       Name	Address	Title	Date of Termination

23. Withdrawals from a partnership or distributions by a corporation

    If your business is a partnership or corporation, list all withdrawals or distributions credited or given to an insider, including compensation in any form, bonuses, loans, stock redemptions, options exercised and any other perquisite during one year immediately preceding the commencement of this case.

     None

    Name and Address of Recipient, and Relationship to You	Date and Purpose of Withdrawal	Amount of Money or Description and Value of Property

24. Tax Consolidation Group

    If the debtor is a corporation, list the name and federal taxpayer identification number of the parent corporation of any consolidated group for tax purposes of which the debtor has been a member at any time within the six-year period immediately preceding the commencement of the case.

     None

    Name of Parent Corporation	Taxpayer Identification Number

25. Pension Funds

    If the debtor is not an individual, list the name and federal taxpayer identification number of any pension fund to which the debtor, as an employer, has been responsible for contributing at any time within the six-year period immediately preceding the commencement of the case.

     None

    Name of Pension Fund	Taxpayer Identification Number