Statement Of Financial Affairs Template Page 6
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12. Safe deposit boxes
List each safe deposit or other box or depository in which the debtor has or had securities, cash, or other valuables
None
within one year immediately preceding the commencement of this case. (Married debtors filing under chapter 12 or
chapter 13 must include boxes or depositories of either or both spouses whether or not a joint petition is filed, unless
the spouses are separated and a joint petition is not filed.)
NAME AND ADDRESS
NAMES AND ADDRESSES
DESCRIPTION
DATE OF TRANSFER
OF BANK OR
OF THOSE WITH ACCESS
OF
OR SURRENDER,
OTHER DEPOSITORY
TO BOX OR DEPOSITORY
CONTENTS
IF ANY
_
______________________________________________________________________________________________________
13. Setoffs
List all setoffs made by any creditor, including a bank, against a debt or deposit of the debtor within 90 days preceding
None
the commencement of this case. (Married debtors filing under chapter 12 or chapter 13 must include information
concerning either or both spouses whether or not a joint petition is filed, unless the spouses are separated and a joint
petition is not filed.)
DATE OF
AMOUNT
NAME AND ADDRESS OF CREDITOR
SETOFF
OF SETOFF
$
_____________________________________________________________________________________________________
14. Property held for another person
List all property owned by another person that the debtor holds or controls.
None
NAME AND ADDRESS
DESCRIPTION AND
OF OWNER
VALUE OF PROPERTY
LOCATION OF PROPERTY
_____________________________________________________________________________________________________
15. Prior address of debtor
None
G
If debtor has moved within three years immediately preceding the commencement of this case, list all premises
which the debtor occupied during that period and vacated prior to the commencement of this case. If a joint petition is
filed, report also any separate address of either spouse.
ADDRESS
NAME USED
DATES OF OCCUPANCY
_____________________________________________________________________________
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