Form 010 - Trustee Questionnaire

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TRUSTEE QUESTIONNAIRE
CASE NUMBER: ______________________
This completed form should be submitted to the Trustee at least 10 days before your Meeting of
Creditors. For questions asking “yes” or “no,” please circle the answer that applies to you. IF YOU
HAVE AN ATTORNEY, YOUR ATTORNEY SHOULD HELPYOU FILL THIS OUT AND THEN THE
ATTORNEY WILL SEND IT TO THE TRUSTEE.
1.
Your name(s): _________________________________________
__________________________________________
2.
Address(s):
_________________________________________
__________________________________________
_________________________________________
__________________________________________
3.
Soc. Sec. No. _________________________________________
__________________________________________
4.
Phone number: (
) __________ - __________________
(
) ___________- __________________
5.
E-Mail Address: _______________________________________
__________________________________________
6.
Marital Status: (circle one): (a) Married & Living Together
(b) Separated
(c) Divorced
(d) Single
(e) Widow(er)
7.
Employment:
Debtor/Husband
Debtor/Wife
Employer Name: ________________________________________
_________________________________________
Payroll address: ________________________________________
__________________________________________
________________________________________
_________________________________________
Employer phone: (
) __________-_________________
(
) __________- _____________________
I am paid:
1/wk.
1/ 2 wks.
2/ mo.
1/ mo.
1/wk.
1 / 2 wks.
2/mo.
1/mo.
7A.
YES
NO
(a) Will you be paying your Chapter 13 Plan payment by automatic wage
deduction from your employer?
(b) If “yes,” and you are married, from whose employer should the wage
deduction be taken?
HUSBAND
WIFE
------------------------------------------------------------------------------------------------------------------------------------------------------------------
8.
YES
NO
(a) Do you have dependents living with you? If “yes,” how many? ______________
YES
NO
(b) Do you have dependents not living with you? If “yes,” how many? __________
9.
YES
NO
(a) Going back 2 years from the date you filed this case, did you at any time
during that period live in a state other than Virginia ?
(b) If “yes,” please list all states in which you lived during the period from 2
years to 2½ years before the date this case was filed:
State
Date moved there
Date left there
___________________________________________________________________________
___________________________________________________________________________
10.
YES
NO
(a) Have you ever filed any kind of bankruptcy case before?
(b) If “yes,” please answer the following questions for every case:
Date filed
State
Chapter
If discharged, date
If dismissed, date
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
1
Form 010; 02/19/08 (version #6)

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