Chapter 13 - Debtor'S Statement Under Penalty Of Perjury Form Page 2
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2TAX RETURNS: □
I have filed state and federal tax returns for each of the four years preceding the filing of my
bankruptcy petition.
□
I failed to file tax returns for the following years:
□
I have not been required to file tax returns since _________ because ________________________________________.
TAX REFUNDS:
The last tax refund I received was: $__________________ DATE: ___________________
REFUND SPENT ON:
WHO DID YOU PAY
HOW MUCH DID YOU PAY
PAYMENT WAS FOR
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Yes
No
Is the copy of the tax return you provided to the Trustee a true copy of the most recent tax return you filed?
LIST INFORMATION REQUESTED FOR ALL REAL ESTATE YOU OWN OR ARE PURCHASING. INCLUDE ALL REAL ESTATE IN
WHICH YOU HAVE ONLY A PARTIAL INTEREST: IF MORE THAN TWO, USE SEPARATE SHEET.
Address:__________________________________________
Address:__________________________________________
Date of purchase & price: _________ $______________
Date of purchase & price:__________ $______________
Lender:___________________________________________
Lender:___________________________________________
Fair market value:$__________________________________
Fair market value:$__________________________________
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Use of property:
Home
Rental
Other
Use of property:
Home
Rental
Other
If rented, rent received is : $________________________
If rented, rent received is : $________________________
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Any other owners beside you?
Yes
No
Any other owners beside you?
Yes
No
name and relationship:
name and relationship:
□
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Yes
No
I have read the Bankruptcy Information Sheet Provided by the United States Trustee.
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Yes
No
I am personally familiar with the information contained in the petition, schedules, statements and related
documents and to the best of my knowledge that information is true and correct.
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Yes
No
I read the petition, schedules, statements, and related documents before I signed them, I signed those items
and the signature upon those items is my own.
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Yes
No
All of my assets are identified on the schedules and all of my creditors are listed on the schedules.
If no, list at the bottom of this page the errors you wish to bring to the Trustee's attention.
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Yes
No
There are no errors or omissions. If no, list at the bottom of this page the errors or omissions you wish to bring to the
Trustee's attention.
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Yes
No
Do you have any claims or cause of action against anyone for breach of contract, personal injury, worker's compensation,
or for any reason? If yes, against whom and for what?
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Yes
No
Have you ever filed bankruptcy before in any court anywhere using the social security number you presented
today, the social security number on the petition, or any other social security number not issued by
the Social Security Administration. If yes, list the case numbers and discharge information at the
bottom of this page.
□
□
Yes
No
Have you consulted with your attorney prior to today?
I STATE UNDER PENALTY OF PERJURY THAT THE ABOVE INFORMATION IS TRUE AND CORRECT:
_______ __________________________________________
______ ________________________________________
DATE
DEBTOR
DATE
DEBTOR
01/15
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