Bankruptcy Questionnaire Template Page 23
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26F.
What was your gross income (reported on W-2 form and tax return) for last year?
YOU
YOUR SPOUSE
__________
__________
G. If you receive alimony, maintenance, or support, what is the amount you get on a regular basis?
YOU
YOUR SPOUSE
__________
__________
H. List all dependents of you and your spouse.
NAME
AGE
RELATIONSHIP
YOU
YOUR SPOUSE
I.
List all members of your household.
NAME
AGE
RELATIONSHIP
J.
Do you expect your income to increase or decrease in the next year? YES ____ NO _____. If YES, describe:
___________________________________________________________________________________________
K. Do you expect to have any increase or decrease in expenses (like medical bills) in the near future?
YES____ NO_____. If YES, describe:
L.
Do you, your spouse, or your dependents receive income from any source other than jobs, alimony, maintenance,
or support listed above (such as public assistance, unemployment compensation, social security, SSI, pension,
etc.)? YES _____ NO _____. If YES, list:
Source of Income
To Whom Payable
Amount per Month
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