Client Worksheet for Bankruptcy and Bill Consolidation

Name(Required)

First Last

Cell Phone Number(Required)

Alternative Phone Number

Spouse Name

First Last

Email(Required)

List Your Dependents and Age

Dependent Name

Dependent age

Marital Status

If you have used, or been known by, any other names within the last 6 years (include maiden names, nicknames, or business names), list them here

Address 1

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

List all other addresses During the last three years.

Date range

Address, City and State

ZIP

Your Occupation

Employer's Name

Employer's Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Work Phone

Years Employed

Spouses Occupation

Spouses Employer's Name

Spouses Employer's Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Spouses work Phone

Spouses Years Employed

List all bank accounts in your name that you have maintained or used in the last year

Bank/Credit Union Name

Account Type

Current Balance

Names on Account

If Closed, Date closed

Checkings/savings, safety deposit boxes, Venmo, PayPal, Apple Cash, etc. (Include all accts in your name: even for a minor child, even accounts with negative balance)

Federal law requires that we have a record of your last six (6) months pay history. You must submit your pay stubs or provide some other proof of income for this time period. Federal law requires your current monthly income and disposable income bet stated. Give estimated average current MONTHLY income: YOU MUST ATTACH LAST 6 MOS. PAYROLL HISTORY OR PAY STUBS

Your Gross Pay (wages/salary/commissions)

Spouse Gross Pay (wages/salary/commissions)

Your Average monthly overtime income

Spouse Average monthly overtime income

Your Take home pay (gross pay less all deductions)

Spouse Gross Pay (wages/salary/commissions)

Your Other income: (Pension, Social Security, etc.)

Spouse Other income: (Pension, Social Security, etc.)

Child Support or Alimony received

For (Name of Person)

Are you expecting any increase or decrease in your income in the next 12 months?

Yes

No

If so, please describe:

Give estimated current MONTHLY expenses: Home Expenses:

Rent or home loan payment 1st Mort.

Rent or home loan payment 2nd Mort.

Real estate Taxes 1st Mort.

Real estate Taxes 2nd Mort.

Utilities:

Electricity

Gas/Oil/Propane

Water/Sewer/Septic

Telephone

Garbage

Satellite

Cable

Internet

Cell Phones

Total Utilities

Home mainenance (repairs and upkeep)

Alimony or child support NOT DEDUCTED FROM WAGES.

Child Name

Child Age

Amount

Insurance (not deducted from wages)

Life

Health

Auto

Homeowners/renter's

Business insurance

Umbrella policy

Other (please specify

Car/Truck payments

Food (groceries and eating out)

Clothing (including uniforms, shoes, etc.)

Laundry and cleaning

Medical costs not paid by insurance ( co-pays, deductibles, medicines, etc.)

Gasoline, vehicle maintenance and repairs .

Education (school fees, student loans, etc.)

Entertainment (movies, newspapers, magazines, etc.)

Tobacco

Child care, preschool or tuition

Haircuts, personal care items

Pet care and supplies

Other expenses give specifics

Are you expecting any increase in your expenses in the next 12 months?

Yes

No

If so, please describe

List all real estate and vehicle, even if they are paid off. IF YOU FAIL TO LIST AN ASSET YOU COULD LOSE THE RIGHT TO A DISCHARGE. YOU COULD BE PROSECUTED FOR BANKRUPTCY FRAUD. YOU COULD LOSE ANY EXEMPTION FOR THAT ASSET WHICH WILL RESULT IN LOSING THE ASSET AL TOGETHER. You will keep your property in most situations, but you must list it completely.

Real Estate (including land contracts, time shares, lease/option contracts, burial lots, etc.)

Address

Approx. Value

Amount Owed

Name on Title/Deed

Auto/Trucks/motorcycles/Boats:

Vehicle Name

Approx. Value

Amount Owed

Title in the Name of

(Please fill out exact year, make and model, including approximate mileage. For example: 2024 Ford F-150, extended bed, extended cab, V8, 4 wheel Drive with 50,000 miles.) You NEED to be specific.

State the approximate amount of cash you generally have on hand or at home

List the value of any Savings Bonds, Stock, Bonds you own

List the value of any IRAs, 40 I (k)s, Pensions or Profit sharing accounts you have

Please state whether you own any Life Insurance and state its cash value

List the value of any debts owed to you (including support)

List the value of any Pending Inheritances

List the value of any Pending Personal Injury Lawsuits

List the value of any Pending Worker's Compensation or Social Security Claims

List the value of any College Savings Plans, tuition credit accounts or Education IRAs you hold for the benefit of any child

HOUSEHOLD ITEMS YOU OWN

Name of Asset

Value

List item name and Approximate Yard Sale or Wholesale Value of your assets. Including but not limited to. Jewelry, Firearm, Boats/Motors/Trailers/Campers, Couch, Charis, TV, Gaming Equipment, Stove, Refrigerator, Microwave, Stereo/Sound Equipment, Living Room Set, Dining Room, Bedroom Sets, Washer, Dryer, Wearing Apparel, Computer, Business Equipment, Tool/Lawn Equipment, Pets/Animals/Livestock

Are any of the items listed here covered by any insurance policy?

Yes

No

Do you own any antiques or collectibles?

Yes

No

Have you listed everything you own or have any interest in?

Yes

No

STATEMENT OF INTENTION

Type of Collateral

Keep

Give Back

If your case is a straight Bankruptcy (Chap. 7), the law requires that you provide a statement as to your intention to keep or give back any collateral that you have securing a debt to a creditor. In the spaces that follow please indicate the type of collateral that you have securing a loan, whether you wish to keep it and continue to pay for it, or give it back. (Mark an X in the appropriate column.)
Generally, creditors will not repossess collateral where the payments are current and the item (such as a home or vehicle) is insured, so please make sure to keep current on those items you wish to keep and make sure to maintain insurance. If you are keeping a vehicle, you will be signing a reaffirmation agreement.

CLIENT CERTIFICATION
The undersigned client(s) hereby represent that the foregoing answers to the questions in this worksheet are true and accurate to the best of their knowledge and belief. Should any changes occur to our financial situation after signing this worksheet, we will notify our attorney. The undersigned understand that to be eligible to file for Bankruptcy they must receive a briefing on credit counseling and budget analysis from a Credit Counseling agency approved by the U.S. Trustee. To receive a discharge under Chapter 7 or Chapter 13, a debtor must attend a personal financial management course approved by the U.S. Trustee. The briefing and course may be provided over the telephone or the Internet.

Date

Client

First Last

Date

Client

First Last

Client Worksheet for Bankruptcy and Bill Consolidation

Step 1: Complete the Bankruptcy Worksheet

Step 2: : Submit Your Creditors

Keegan and Co Attorneys, LLC

Contact Us

Eastgate Location

Middletown Location

Ohio Bankruptcy Attorney