BANKRUPTCY INTAKE SHEET
Full Names:
Husband 		Wife
Marital Status and Filing Status
___single
___married, filing jointly 		___married, filing separately
___separated, filing separately
___ separated, filing jointly
List all other names you have been known by. (Example: maiden name before being married):
Husband                                                                                 Wife
Home phone:
Work phone:
County you live in:
Mailing Address:
Husband's SSN:
Wife's SSN:
Husband's Employer:Job title: Wife's Employer:Job title:
Address:
Address:
How long employed there? How long employed there?
INCOME
Husband Wife
Circle one: Weekly, Bi-weekly, Bi-monthly, Monthly Circle one: Weekly, Bi-weekly, Bi-month, Monthly
Gross: Gross:
Deductions: Deductions:
Retirement: Retirement:
Taxes: Taxes:
Credit Union: Credit Union:
Insurance: Insurance:
Other: Other:
Net Pay: Net Pay:
Any other income: Any other income:
Total: Total:
BUDGET
1) Rent/Mortgage: 16) Health Ins.:
2) Utilities/Lights: 17) Auto Ins.:
3) Water: 18) Other Ins.:
4) Telephone: 19) Transportation:
5) Cable TV: 20) Recreation:
6) Gas: 21) Child care:
7) Other utilities: 22) Dues/Professional:
8) Home maintenance: 23) Alimony/support:
9) Food: 24) Other Family:
10) Clothing: 25) Taxes:
11) Laundry: 26) Car payment:
12) Books & School: 27) Miscellaneous:
13) Medicine & Drugs: 28) Charitable Contributions:
14) Insurance/Homeowners: 29) Other
15) Life Ins.: Total:
LIFE INSURANCE WITH CASH VALUE IRA ACCOUNT
Company name:
 ___________________________
Institution:
 _________________________
Policy Number:
 ___________________________
Address:
_________________________
Cash value:
___________________________
_________________________
Beneficiary:
___________________________
Account Number:
_________________________
Insured:
 ___________________________
Balance:
_________________________
    
SAVINGS ACCOUNTS SAVINGS ACCOUNTS
Institution:
 ___________________________
Institution:
 _________________________
Address:
 ___________________________
Address:
_________________________
  
Account Number:
  
Account Number:
 
  ___________________________   _________________________
  ___________________________   _________________________
    

CHECKING ACCOUNTS
OTHER BANK ACCOUNTS
Institution:
 ___________________________
Institution:
 _________________________
Address:
 ___________________________
Address
 _________________________
Account Number:
 ___________________________
Account Number:
_________________________
Balance:
___________________________
Balance:
_________________________
        
FOR BOTH SPOUSES IF FILING JOINTLY
Income from employment
or operation of a business:		 Income from other than employment
or operation of a business:
For this year to date:
 ___________________________
For this year to date:
_________________________
Last year:
 ___________________________
Last year:
_________________________
Year before last:
___________________________
Year before last:
_________________________
        
Have you purchased any property within the last 90 days that you want to keep?
____________________________________________________________________________________________
____________________________________________________________________________________________
Have you taken any cash advances greater than $1000 within the past 60 days?
____________________________________________________________________________________________
____________________________________________________________________________________________
Have you purchased any luxury goods greater than $1000 within the past 60 days? If yes, provide details
____________________________________________________________________________________________
____________________________________________________________________________________________
Do you expect to receive any inheritances, insurance proceeds, property settlements or gifts within the next 180 days?
If yes, provide details.
____________________________________________________________________________________________
____________________________________________________________________________________________
Have you sold, given away or otherwise transferred any property to anyone in the past year?
If yes, please describe property, its value, and to whom it was transferred.
____________________________________________________________________________________________
____________________________________________________________________________________________
Have you lived at your current address for at least two years?
If not, provide addresses where you have lived for the last two years.
____________________________________________________________________________________________
____________________________________________________________________________________________
Have you or your spouse lived outside North Carolina for the last six years? If yes, where and when?
____________________________________________________________________________________________
____________________________________________________________________________________________
Have there been any attachments of your property in the last year? Has your salary been garnished? If yes, provide details
____________________________________________________________________________________________
____________________________________________________________________________________________
Has any property of yours been taken in a foreclosure or repossession action in the last year? If yes, provide details.
____________________________________________________________________________________________
____________________________________________________________________________________________
Has any property of yours been assigned to a creditor in the last six months? Has any of your property been controlled
by a custodian or court appointed official in the last twelve months? If yes, provide details.
____________________________________________________________________________________________
____________________________________________________________________________________________
Have you made any gifts or charitable contributions worth more than $100.00 in the last year? If yes, provide details.
____________________________________________________________________________________________
____________________________________________________________________________________________
Do you owe any back taxes? Please provide information about year, taxing authority and amount owed.
____________________________________________________________________________________________
____________________________________________________________________________________________
Have you paid anyone to help you with debt counseling in the last year? If yes, provide details.
____________________________________________________________________________________________
____________________________________________________________________________________________
Have you had a safe deposit box in the last twelve months? If yes, provide details.
____________________________________________________________________________________________
____________________________________________________________________________________________
Has your bank or other institution taken money from and account of yours to cover a debt you owe the bank in the last 90 days? If yes, provide details.
____________________________________________________________________________________________
____________________________________________________________________________________________
 
If you have been an officer, director or owner of a business in the last six years, provide the following:
Name of Business: __________________________________________________________________
Start & end date of operation:__________________________________________________________
Tax ID Number:_____________________________________________________________________
Nature of business:__________________________________________________________________
Sole proprietorship, corporation or partnership?:____________________________________________
(If you were or are the owner, provide an inventory of property owned by the business and a list of its debts)
Name and address of accountant or keeper of books:________________________________________
_________________________________________________________________________________
Have you ever owned real estate with environmental problems? Provide details.
____________________________________________________________________________________________
____________________________________________________________________________________________
List below all payments on loans, installment purchases of good or services, and other debts, totaling more than $600 to any creditor, made within the past 90 days.
Name & Address of Creditor:
Payment date/s:
Amount paid:
Amount owed:
________________________________________
________________
________________
________________
________________________________________
________________
________________
________________
________________________________________
________________
________________
________________
________________________________________
________________
________________
________________

List below all payments made within the past year to or for the benefit of creditors who are or were insiders.
Name & Address of Creditor and Relationship to Debtor:
Payment date/s
Amount paid
Amount owed
________________________________________
________________
________________
________________
________________________________________
________________
________________
________________
________________________________________
________________
________________
________________
List all suits and administrative proceedings to which you are or were a party within the past year.
Caption of Suit & Case Number:
Nature of Proceeding:
Court or Agency and Location:
Status or Disposition:
_______________________
________________
______________________
_______________
_______________________
________________
______________________
_______________
List below any bank accounts or financial accounts which were closed in the past year.
Name & Address of Institution:
Type & Number of Account
and amount of final balance:
Amount and date of sale or closing:
_______________________
_______________________
_______________________
_______________________
_______________________
_______________________
_______________________
_______________________
_______________________
     

List below all property owned by another person that you hold or control.
Name & Address of Owner
Description & Value of Property
Location of Property
_______________________
_______________________
_______________________
_______________________
_______________________
_______________________
_______________________
_______________________
_______________________
PROPERTY
Home
Market value: $ 		Purchase date:
Purchase price: $ Monthly payment amount:
Number of months behind on payments:  
Automobiles
First Auto (year, make, and model):
Value: Mileage: Monthly payment amount:
Purchase date: Purchase amount:
Number of months behind on payments:
Second Auto
(year, make, and model):
Value: Mileage: Monthly payment amount:
Purchase date: Purchase amount:
Lien Holder:
Number of months behind on payments:
Third Auto
(year, make, and model):
Value: Mileage: Monthly payment amount:
Purchase date: Purchase amount:
Number of months behind on payments:
Mobile Home
(year, make, and model):
Dimensions:
Purchase date: Purchase amount:
Number of months behind on payments:

DEBTS SECURED BY COLLATERAL (EXAMPLES: HOME MORTGAGE, CAR LOAN, MOBILE HOME LOAN, FURNITURE LOAN) YOU MUST INCLUDE A DATE THE DEBT WAS INCURRED.

Creditor name: Name on account
Creditor Address: Account number:
Amount owed: $
Collateral:
Date of Claim:
Monthly payment: $
Creditor name: Name on account
Creditor Address: Account number:
Amount owed: $
Collateral:
Date of Claim:
Monthly payment: $
Creditor name: Name on account
Creditor Address: Account number:
Amount owed: $
Collateral:
Date of Claim:
Monthly payment: $
Creditor name: Name on account
Creditor Address: Account number:
Amount owed: $
Collateral:
Date of Claim:
Monthly payment: $
Creditor name: Name on account
Creditor Address: Account number:
Amount owed: $
Collateral:
Date of Claim:
Monthly payment: $
Creditor name: Name on account
Creditor Address: Account number:
Amount owed: $
Collateral:
Date of Claim:
Monthly payment: $
UNSECURED DEBTS  (EXAMPLES OF UNSECURED DEBTS - CREDIT CARDS, MEDICAL BILLS, PERSONAL LOANS, PERSONAL SERVICES. IF THERE IS A COLLECTION AGENCY OR ATTORNEY INVOLVED, PROVIDE THAT INFORMATION AS WELL):
Creditor name: Name on account
Creditor Address: Account number:
Amount owed: $
Nature of the debt
Creditor name: Name on account
Creditor Address: Account number:
Amount owed: $
Nature of the debt
Creditor name: Name on account
Creditor Address: Account number:
Amount owed: $
Nature of the debt
Creditor name: Name on account
Creditor Address: Account number:
Amount owed: $
Nature of the debt
Creditor name: Name on account
Creditor Address: Account number:
Amount owed: $
Nature of the debt
Creditor name: Name on account
Creditor Address: Account number:
Amount owed: $
Nature of the debt
Creditor name: Name on account
Creditor Address: Account number:
Amount owed: $
Nature of the debt
Creditor name: Name on account
Creditor Address: Account number:
Amount owed: $
Nature of the debt
Creditor name: Name on account
Creditor Address: Account number:
Amount owed: $
Nature of the debt
Creditor name: Name on account
Creditor Address: Account number:
Amount owed: $
Nature of the debt
Creditor name: Name on account
Creditor Address: Account number:
Amount owed: $
Nature of the debt
Creditor name: Name on account
Creditor Address: Account number:
Amount owed: $
Nature of the debt
Creditor name: Name on account
Creditor Address: Account number:
Amount owed: $
Nature of the debt
Creditor name: Name on account
Creditor Address: Account number:
Amount owed: $
Nature of the debt
Creditor name: Name on account
Creditor Address: Account number:
Amount owed: $
Nature of the debt
Creditor name: Name on account
Creditor Address: Account number:
Amount owed: $
Nature of the debt
Creditor name: Name on account
Creditor Address: Account number:
Amount owed: $
Nature of the debt
Creditor name: Name on account
Creditor Address: Account number:
Amount owed: $
Nature of the debt
Creditor name: Name on account
Creditor Address: Account number:
Amount owed: $
Nature of the debt
Creditor name: Name on account
Creditor Address: Account number:
Amount owed: $
Nature of the debt
Creditor name: Name on account
Creditor Address: Account number:
Amount owed: $
Nature of the debt
Creditor name: Name on account
Creditor Address: Account number:
Amount owed: $
Nature of the debt
Creditor name: Name on account
Creditor Address: Account number:
Amount owed: $
Nature of the debt

INVENTORY OF PERSONAL PROPERTY

Household furniture, china, silverware, jewelry, appliances, musical instruments, artwork, recreational equipment, photographic, and stereo equipment (make a complete list and estimate the fair market value of each item. Fair market value is the value you would have to pay for the item in its present condition) Summarize list below as follows:

DESCRIPTION
FAIR MARKET VALUE
LIEN-HOLDER
LIEN AMOUNT
Clothing & personal
     
Kitchen appliances      
Stove      
Refrigerator      
Freezer      
Washing machine      
Dryer      
China      
Silver      
Jewelry
     
Living room furniture      
Den furniture      
Bedroom furniture      
Dining room furniture      
Lawn furniture      
Television      
Stereo      
Radio      
VCR      
Video Camera      
Musical Instruments      
Piano ( ) Organ ( )      
Air Conditioner      
Paintings/Art      
Lawn mower      
Professional Tools      
Yard Tools      
Crops      
Recreational Equipment      
Computer      
Total:
     

List any dependents or others who reside with you:
Name: Age: Relationship:
     
     
     
     
     
     

List any money owed to you or any claims you have against someone. Examples: tax refunds you have a right to
(unpaid loans, personal injury awards, etc.)
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
List any bankruptcies (with your case number) you have filed in the past six years:
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________

PLEASE READ THE FOLLOWING DISCLOSURE AND SIGN YOUR NAME THAT YOU UNDERSTAND:

I (We) certify that the bills listed or attached hereto are all the bills we owe.
I (We) certify that we specifically understand that Michael C. Gold has not searched the public record
or obtained credit reports, but has relied on the information we have listed here.
I (We) certify that the information contained in this application is correct to the best of our knowledge.
I (We) understand that all bankruptcies are a matter of public record and may be viewed on the internet
by anyone with a computer.

_______________________________________ _______________________________________
Your Signature Date Spouse Signature Date