Supplemental Hearing Questionnaire Template printable pdf download

SUPPLEMENTAL HEARING QUESTIONNAIRE

NAME:_____________________ CASE NUMBER:____________________ DATE:___________________

QUESTIONS:

1. Debtor=s Name:____________________________________ Date of Birth___________________________

Spouses Name: ____________________________________ Date of Birth___________________________

2. Address:________________________________________________________________________________

3. Telephone#:__________________Work #:___________ Cellphone__________ E-mail_________________

4. Social Security Number: Mr.___________________________ Mrs._________________________________

5. How many children?_________________ How many other dependants?_____________________________

6. What are their ages?_______________________________________________________________________

7. Do any of them pay room and board (if yes, who and how much?)__________________________________

8. Where are you working? (Name, Address & phone#): ____________________________________________

__________________________________________________________________________________________

9. What is your occupation?_________________________ What is your salary?_________________________

10. Where does your spouse work?_____________________________________________________________

11. What occupation?_________________________ What is the salary?_______________________________

12. Do you own real estate? (Value and location)__________________________________________________

BANK ACCOUNTS: Bank name

Names on account

Type of account

Account#

__________________________________________________________________________________________

Safety deposit Box?___________ If so, where and describe contents: __________________________________

13. How much cash do you have right now? $______ Do you have cash anywhere else?_____ How much?____

14. Describe your household furniture: __________________________________________________________

__________________________________________________________________________________________

15. Personal Property (other than household furniture & wearing apparel): _____________________________

__________________________________________________________________________________________

16. List the names of people who owe you money, their addresses and the amount they owe you:

_____________________________________________________________________________________

__________________________________________________________________________________________

17. List Stocks, bonds, or other securities: _______________________________________________________

__________________________________________________________________________________________

18. List watches, diamonds, jewelry, computers, electronics, etc.: ____________________________________

__________________________________________________________________________________________

19. List automobiles, other vehicles, trucks, you have any interest in (get VIN number): ___________________

__________________________________________________________________________________________

20. Are you going to receive a tax refund?(How much and when?)____________________________________

21. List farm implements or livestock: __________________________________________________________

22. List any inheritance you may be receiving: ____________________________________________________

23. How do you intend to settle this lawsuit?_____________________________________________________

_________________________________________________________________________________________

***BRING DOCUMENTS TO SUPPORT STATEMENTS MADE ABOVE: Social Security Card, Pay

Check Stubs, Bank Account Statements, Titles to vehicles, Property, Stock Statements, etc.

YOU ARE REQUIRED TO PRODUCE THESE DOCUMENTS - FAILURE TO

DO SO COULD RESULT IN A CONTEMPT OF COURT CHARGE BEING

BROUGHT AGAINST YOU!

Supplemental Hearing Questionnaire Template

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