Chapter 13 Trustee Questionnaire & Document Request Form Page 2

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DEBTOR NAME(S)________________________________________ CASE NUMBER ______________
CHAPTER 13 TRUSTEE QUESTIONNAIRE & DOCUMENT REQUEST
__YES __NO
__YES __NO
10. Do you have any claims against anyone?
__YES __NO
__YES __NO
11. Have you filed or do you have a reason to file a
lawsuit against anyone?
__YES __NO
__YES __NO
12. Are you a beneficiary of any will, trust, or estate?
__YES __NO
__YES __NO
13. Are you currently entitled to any life insurance
proceeds or inheritance as a result of someone’s
death?
__YES __NO
__YES __NO
14. Has there been a change in your financial situation
since the filing of the bankruptcy?
__YES __NO
__YES __NO
15. Did you make any payments totaling over $600 to
any unsecured creditor in the 90 days prior to filing
bankruptcy?
__YES __NO
__YES __NO
16. Did you rearrange your financial affairs in any way in
preparation for the filing of this bankruptcy?
__YES __NO
__YES __NO
17. Have you transferred any credit card balances from
one to another during the last six months?
__YES __NO
__YES __NO
18. Is anyone holding or storing anything on your
behalf?
__YES __NO
__YES __NO
19. Do you have a safe-deposit box or a self-storage
unit?
__YES __NO
__YES __NO
20. Have you repaid any loans to any friends or family
during the last year?
__YES __NO
__YES __NO
21. Do you have a domestic support obligation to pay
child support, maintenance, or alimony (if yes, you
will be required to submit an additional form)?
PART IV: DECLARATION UNDER PENALTY OF PERJURY
I DECLARE UNDER PENALTY OF PERJURY THAT I HAVE PERSONALLY READ THIS
QUESTIONNAIRE AND TRUTHFULLY ANSWERED ALL THE QUESTIONS. I FURTHER DECLARE
THAT THE INFORMATION AND DOCUMENTS PROVIDED WITH THIS QUESTIONNAIRE ARE ALSO
TRUE, COMPLETE AND ACCURATE TO THE BEST OF MY KNOWLEDGE.
Debtor Signature: ______________________
Joint Debtor Signature: ______________________
Debtor Printed Name: ___________________
Joint Debtor Printed Name: ___________________
Date: ______________
Date: ______________
Phone Number: ___________________
Phone Number: ___________________
Email: ___________________
Email: ___________________

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