Bankruptcy Questionnaire Template Page 25
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26Gasoline and oil
$
Newspapers, magazines, school books
$
Recreation
$
Charitable contributions
$
Club and union dues
(not deducted from wages)
$
Insurance (not deducted from wages)
Homeowner’s or renter’s
$
Life
$
Health
$
Auto
$
Other
$
Taxes (not deducted from wages
or included in mortgage payment)
$
Tax return preparation fees
$
Checking account and other bank fees
$
Loan installment payments
Auto
$
Other
$
Other
$
Alimony, maintenance or support payments
$
Child support and other payments for
support of dependents
$
Expenses for operating your business
$
Other expenses (list types of expenses, e.g.,
cigarettes, diapers, security system, school,
birthday and holiday gifts, pets)
Identify:
$
$
$
P.
If you and your spouse are not filing bankruptcy together, does your spouse (who is not filing bankruptcy) have any
monthly expenses listed above that are not paid towards your household expenses (such as child support payments
your spouse makes to a former spouse or payments your spouse makes on separate debts)? YES _____ NO _____.
If YES, list:
Describe Expense Item
To Whom Payable
Amount per Month
Q. Do you have any monthly expenses not listed above that you pay for the care and support of an elderly,
chronically ill, or disabled member of your household or your immediate family? YES____ NO_____.
If YES, describe:
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Parent category: Financial