Financial Statement Of Debtor (Submitted For Government Action On Claims Due The United States) Page 3

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REAL PROPERTY/FARM LAND/VACATION/RENTAL
42. Are you buying the home in which you live?
Yes
No
Are you buying or do you own real property other than your home
Yes
No?
If yes, list the address and description of the property:
43. List the value of each piece of property and your equity in it:
$--------------------------------------------------
44. Is any of the above listed property owned jointly with anyone else?
Yes
No
If yes, list property and name of co-owner.
45. Are you making mortgage payments?
Yes
No
If yes, amount
$--------------------------------------------------
46. Do you rent the property to others?
Yes
No
If yes, what is the net income to you?
$--------------------------------------------------
47. Does your spouse/companion solely own real property?
Yes
No
If the answer is yes, list the property address and value
$--------------------------------------------------
48. FIXED MONTHLY EXPENSES (Fill in Blanks)
Rent/Mortgage
$------------------------
Home Insurance & Taxes
$ --------------------
List only if paid directly by you
Car Payment
$------------------------
Car Insurance
$---------------------
Gasoline
$------------------------
Water
$---------------------
Electricity
$------------------------
Telephone
$--------------------
Natural Gas
$ ------------------------
Other Utilities (Specify)
$--------------------
Cable TV
$------------------------
Public Transportation
$--------------------
Food
$----------------------
Other
$--------------------
Internet Service
Provider
$----------------------
Subtotal
$------------------------
Subtotal
$--------------------
Grand Total
$--------------------------------------
List credit card, installment or other payments
Creditor
Date of Debt and Purpose
Total Amount Due
Date of last Payment
Payment Amount
Frequency
(Additional Space needed use back of last page)
3

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