Debtor Personal Information

Full Legal Name

Any Other Names Used in the Last 8 Years (maiden, aliases)

Date of Birth

Social Security Number

Maritial Status

Select an option Single Married Separated Divorced Widowed

Is your spouse also filing?

Select an option Yes No

County of Residence

How long have you lived in California?

Have you filed Bankruptcy before?

Yes

Chapter filed, year, and district

No

Employment & Income

Current Employment Status

Employer Name and Address

How long with current employer?

Monthly Gross Income (wages/salary)

Spouse's Monthly Gross Income (even if not filing)

Have you been self-employed in the last 6 years?

Yes

Business name, type, and dates of operation

No

Monthly Expenses

Rent or Mortgage Payment

Utilities (electricity, gas, water, internet)

Food / Groceries

Transportation (car payment, gas, insurance, public transit)

Health Insurance / Medical Expenses

Childcare / Education

Other Regular Monthly Expenses (describe)

Assets

Do you own or have an interest in any real estate?

Yes

Address, estimated value, and amount owed

No

Do you own a vehicle?

Yes

Year, make, model, estimated value, and loan balance

No

Do you have bank or credit union accounts?

Yes

Institution name(s) and approximate balance(s) Institution name(s) and approximate balance(s) Institution name(s) and approximate balance(s)

No

Do you have retirement accounts (401k, IRA, pension)?

Yes

Type and approximate balance

No

Do you own any business interests?

Yes

How many percentage share? What is the Entity number

No

Do you expect to receive any inheritance, insurance proceeds, or tax refund within the next 6 months?

Yes

No

Debts & Creditors

List all credit card debts (creditor name, last 4 digits of account, balance owed)

List all medical debts (provider name, approximate balance)

List all personal loans (lender name, balance owed)

List any tax debts (federal or state, year, and amount)

Are any wages currently being garnished?

Yes

Are any lawsuits or judgments pending against you? Case name, court, and status

No

Has any property been repossessed or foreclosed in the last year?

Yes

Which property?

No

Are you behind on any mortgage or car payments?

Yes

How many payments? How many months?

No

Financial History (Statement of Financial Affairs)

List any payments of $600 or more made to a single creditor in the last 90 days

List any payments made to a family member or close associate in the last 1 year

Have you sold, transferred, or given away any property in the last 2 years?

Yes

Describe what was transferred, to whom, and for what value

No

Have you been a party to any lawsuit in the last 1 year?

Yes

No

Have you had any income from sources other than employment in the last 2 years?

Yes

Describe source and amounts

No

Credit Counseling Requirement

Have you completed an approved credit counseling course?

Yes

Provider name and date of completion

No

Document Upload

Government-issued photo ID

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Social Security Card

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Paystubs

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2 year tax return

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1 Month bank statement

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Certificate of first debtor course

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Client Certification

I declare under penalty of perjury that all information provided in this questionnaire is true, accurate, and complete to the best of my knowledge. I understand that TrustPoint Disability & Legal Services prepares legal documents and does not provide legal advice or legal representation. I understand that all debts and assets must be fully disclosed, and that omissions may result in consequences including denial of discharge.

Yes

No

Date