milly whatley, p.c.millywhatley.procurrox.com/wp-content/uploads/sites/3988/... · 2018. 1. 8. ·...

Tel: 541-312-5392 Fax: 541-312-8334 Email: [email protected]

Milly Whatley, P.C. Attorney-at-Law

2445 NE Division St., Ste. 202 Bend, Oregon 97703-3568

Thank you for considering our office for help with your financial needs. Please call (541) 312-5392 to schedule your free consultation. You will need to complete and bring with you the Initial Questionnaire. If you are self-employed, you will also need to complete the Supplemental Questionnaire for the Self-Employed. Please complete these forms even if you intend to inquire about debt resolution options other than bankruptcy. In order to assess your situation it is essential that all household income be disclosed. Therefore, please complete the questions relating to “Spouse/Domestic Partner” if your spouse, fiancé, or other “significant other” resides with you, even if only you are considering bankruptcy. Please bring with you to your appointment:

1. The completed and signed questionnaire. 2. A copy of your most recently filed tax return. 3. A recent pay stub, if you are employed.

If you are contemplating bankruptcy:

1. Stop ALL use of credit cards, including balance transfers and cash

advances. 2. Do not take any payday loans. 3. Do not put assets in someone else’s name, or dispose of any assets

unless you sell them for fair market value. 4. Do not cash in any IRA’s, 401(k)’s or other retirement funds. 5. Keep all statements and correspondence you receive from your

creditors. 6. Keep all your pay stubs.

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INITIAL FINANCIAL QUESTIONNAIRE

Client Spouse or Domestic Partner

Legal Name Full Legal Name Full Legal Name

All other names used in last 8 years

Social Security Number

Date of Birth

Home Phone

Business Names used in last 8 years

EINs (Employer ID Numbers) used in last 8 years

Cell Phone

Email Address

Street Address

Address Line 1

City State Zip

County

Address Line 2 (if needed)

Address Line 1

City State Zip

County


Mailing Address (if different)

Address Line 1

City State Zip

County


Address Line 1

City State Zip

County


Revised January 2018

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Acres:

Do you want to keep this property?

ADDRESS:

Date Purchased: Is this a Time Share?

What do you believe the fair market value of this property is at this time?

Please explain why:

Mortgage Company Name

Mortgage Company Address

Mortgage company name and address:

Amount in Arrears



Total Amount Owed: Monthly Payment:

Second Mortgage company name and address:

Amount in Arrears



Total Amount Owed: Monthly Payment:

Third Mortgage company name and address:

Amount in Arrears Total Amount Owed: Monthly Payment:

Do you have any other liens on your property such as a judgment or tax lien? YES NO

YES NO YES NO

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(OTHER THAN REAL ESTATE LISTED ON PAGE 2)

Do you have debts that are secured by collateral such as car loans, or items that you have fi-

nanced such as furniture, tires, computers, etc? YES NO

If YES complete this page with all items. If NO, go to page 4.

NO

Description of the collateral:

Lender Name:

Lender Address:

Do you want to keep this collateral? YES

Are you current on your payments? YES NO

NO


Lender Name:

Lender Address:



NO


Lender Name:

Lender Address:



NO


Lender Name:

Lender Address:



NO


Lender Name:

Lender Address:



ATTACH ADDITIONAL PAGES IF NECESSARY

Current Fair Market ValueBalance Owed





Default

Typewritten Text

Add mileage for vehicles

4 of 20

Complete the following for each vehicle and boat that you own, or that is titled or co-titled in your name. This includes cars, trucks, trailers, horse trailers, RVs, tractors, campers, motorcycles, ATVs, and snowmobiles. Please list the co-owner if applicable. You do not need to list vehicles you have already listed on page 3.

Year: Make: Model:

Mileage: Co-Owner: Present Value:

Year: Make: Model:


Year: Make: Model:


Year: Make: Model:


Year: Make: Model:


Year: Make: Model:


Year: Make: Model:


Year: Make: Model:


Year: Make: Model:

Mileage Co-Owner: Present Value

Year: Make: Model:



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For each of the following assets that you own, estimate the value the asset would bring if you sold it at an auc-tion, garage sale, or pawn shop. DO NOT put the replacement value or insured value.

LIST ALL ASSETS! Even household goods with very little or no value such as costume jewelry, clothing, pets (you will not lose your pet in bankruptcy) must be listed.

ASSET

GARAGE SALE VALUE

General Household Goods: furniture, appliances, lamps, rugs, dishes, cookware, tools

Electronics: TVs, computers, printers, scanners, cell phones, cameras, media players, games

Collectibles of Value: books, artwork, collections such as coins, stamps, and/or baseball cards

Sports Equipment: exercise equipment, bicycles, golf clubs, skis, canoes, kayaks

Musical Instruments (what kind?):

Hobby Equipment (what kind?):

Rifles (how many?):

Shotguns (how many?):

Handguns (how many?):

Clothing:

Jewelry (including costume jewelry, watches, & wedding bands):

Pets (what kind?):

Horses (how many?):

Other farm animals (how many?):

Tools for business use:

Other assets:

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List ALL bank accounts you presently have open. Include accounts that are overdrawn, accounts with very small balances, and accounts you seldom use. Include accounts such as any parent's or children’s accounts that haveyour name on them even if the money belongs to someone else.

Current Balance:

Name of Bank:

Type of Account (savings, checking, etc):

Name of other person on the account (if applicable):

Current Balance:

Name of Bank:



Current Balance:

Name of Bank:



Current Balance

Name of Bank:



Have you closed any bank accounts in the last 12 months? YES NO

If YES complete the following section. If NO, go to page 7.

Date Account Closed:

Name of Bank:


Closing Balance:

Date Account Closed:

Name of Bank:


Closing Balance:


(ATTACH ADDITIONAL PAGES IF NECESSARY)

Current Balance

Name of Bank:



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(if YES, please describe

Bonds, mutual funds, or publicly traded stocks? YES NO

Non-publicly traded stock or interests in incorporated or unincorporated YES NO

businesses, including interests in an LLC, partnership, or joint venture?

Government or corporate bonds or other non-negotiable instruments? YES NO

IRA, 401(k), or other retirement or pension account? YES NO

Security deposits or prepayments for rent or utilites? YES NO

Annuities (contract for periodic payment of money to you)? YES NO

Educational IRA or similar account for educational expenses? YES NO

Trusts or equitable or future interests in property? YES NO

Patents, copyrights, trademarks, trade secrets, or other intellectual property? YES NO

Licenses, franchises, or other intangible property? YES NO

Life insurance? YES NO

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Zip State City

Address

Name

HAVE YOU FILED ALL TAX RETURNS THAT ARE DUE? YES NO

If NO, list what tax returns need to be filed:

WHAT YEARS?

Internal Revenue Service

Oregon Department of Revenue

Other State:

Have you received all tax refunds you are entitled to receive? YES NO

If NO, how much do you expect to receive? When?

DO YOU OWE ANY TAXES? YES NO

If YES, complete this section. If NO, go to next section.

Taxing Authority (such as IRS, Dept. of Revenue, etc):

Type of Tax (such as income or property):

For what years? Amount Owed:

When was this tax return filed?

Taxing Authority (such as IRS, Dept. of Revenue, etc):

Type of Tax (such as income or property):

For what years? Amount Owed:

When was this tax return filed?

YES NO

YES NO

YES NO

Do you any spousal support (alimony) or child support?

If YES, complete this section. If NO, go to page 9.

What is the monthly amount of your support payment?

Is it currently being deducted from your paycheck?

How much back support do you owe now?

Is your support paid to the Oregon Department of Justice?

List name and address of person who receives the support:

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Which of the following types of debts do you have?

Credit Cards Medical Bills

Judgments against you Unsecured lines of credit

Student loans Personal debts to relatives or friends

Overdue rent or utility bills Payday loans

Other unsecured debts

For each of the above type of debts, complete the following section listing each debt, the creditor’s name and

address, and current balance. If the debt has been assigned to a collection agency, include the name and address

of the collection agency also.

Please Note: You are required to list all debts even if you intend to repay some of them.

State City Address Zip

Agency Name


Creditor Name: Balance:

In collections? YES NO

If YES, Name and Address of Collection Agency:


Agency Name






Agency Name






Agency Name





Continued on next page →

10 of 20



Agency Name






Agency Name






Agency Name






Agency Name






Agency Name






Agency Name





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Name

Address

City State Zip

Name and Address of Creditor:

Item Leased:

Do you wish to keep this item? YES NO


Name

Address

City State Zip

Name and Address of Creditor:

Item Leased:

Do you wish to keep this item? YES NO


Name

Address

City State Zip

Name and Address of other Party to Contract:

Description of Contract:

Do you wish to continue this contract? YES NO

Name

Address

Name and Address of other Party to Contract:

Description of Contract:

Do you wish to continue this contract? YES NO


City State Zip

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Name

Address

City State Zip

Name and Address of Co-Debtor:

Name of Creditor:

Name

Address

City State Zip


Name of Creditor:

Name

Address

City State Zip


Name of Creditor:

Name

Address

City State Zip


Name of Creditor:

Name

Address

City State Zip


Name of Creditor:


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IS CLIENT OR SPOUSE/DOMESTIC PARTNER EMPLOYED? YES NO

If YES, complete this page. If NO, go to page 14

Name

Address

City State Zip

Client Occupation:

Employer’s Name and Address:

Date you became employed there:

Dates you get a paycheck:

Gross pay (before taxes) each paycheck:

Net pay (after taxes) each paycheck:

Second job (if applicable):

Monthly Net from second job:

Name

Address

City State Zip

Spouse/Domestic Partner Occupation:

Employer’s Name and Address:

Date you became employed there:

Dates you get a paycheck:

Gross pay (before taxes) each paycheck:

Net pay (after taxes) each paycheck:

Second job (if applicable):

Monthly Net from second job:

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YES NO

If YES, complete this page. If NO, go to page 15

State the amount of monthly income you receive from each source below:

CLIENT:

Social Security:

Pension/Retirement

Unemployment

Disability

Alimony (spousal support)

Child Support

Rental Income

Food Stamps

Other (list types and amounts):

SPOUSE/DOMESTIC PARTNER:

Social Security:

Pension/Retirement

Unemployment

Disability

Alimony (spousal support)

Child Support

Rental Income

Food Stamps

Other (list types and amounts):

Type:

Type:

Type:

Amount:

Amount:

Amount:

Amount:

Amount:

Amount:

Type:

Type:

Type:

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Please list below your average monthly expenses. For example, for most people water is more expensive in the summer months and electricity and heat are more expensive during the winter months. List the average over the course of a year.

For expenses that you do not incur every month (such as home maintenance or clothing), estimate your yearly expenditure and divide by twelve.

Medical and dental expenses: do not include payments on past due debts. List what you expect to incur on a monthly basis in the future for expenses such as prescriptions, co-pays, vision and dental exams, and other medi-cal expenses not covered by insurance.

Rent or Mortgage:

Insurance included? YES NO

If NO, insurance not included in rent/mortgage:

Taxes included? YES NO

If NO, taxes not included in mortgage:

Home Maintenance/Upkeep:

Homeowner Association Dues:

Additional Mortgage Payment for residence:

Electricity, Heat, Natural Gas:

Water, Sewer, Garbage:

Phone, Cell, Internet, TV:

Other Utilities (specify):

Food & Housekeeping Supplies:

Childcare & School Expenses:

Clothing, Laundry, & Dry Cleaning:

Personal Care Products & Services:

Ongoing Medical & Dental NOT paid by insurance (co-pays, out of

pocket prescription costs, eyeglasses, contacts, etc.):

Pet Care:

Auto Maintenance & Gas:

Recreation, Books, & Magazines, Clubs:

Charitable Contributions:

Life Insurance:

Health Insurance, NOT deducted from your paycheck (specify):

Auto Insurance:

Other Insurance (specify):

Taxes, NOT deducted from your paycheck (specify):

Car Loan or Lease (1st):

Car Loan or Lease (2nd):

Other Installment Payments (specify):

Child Support or Alimony NOT deducted from paycheck:

Mortgages on other property:

Additional Expenses on other property

(taxes, insurance, maintenance):

Any additional expenses (specify):

Utility Type

Utility Type

Description

Description

Description

Amount

Amount

Amount

Amount

Amount

Description Amount

Description Amount

Description Amount

Amount

Amount

Descripition

Descripition

Descripition

Descripition

Amount

Amount

16 of 20

Do you have children who stay with you less than full time? YES NO

If so, do you claim them as dependents on your tax return? YES NO

When did you move into your present address?

If you have not lived at your present address for the last two years, list all prior addresses for the last three years with the date you lived at each residence.

Address

City State Zip

Dates: From to

Address:

IF YOU HAVE NOT LIVED IN OREGON FOR THE LAST SIX YEARS, LIST ALL OTHER STATES WHERE YOU LIVED DURING THAT TIME.

Address

City State Zip

Dates: From to

Address:

Address

City State Zip

Dates: From to

Address:

Address

City State Zip

Dates: From to

Address:

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INCOME FROM WAGES OR SELF-EMPLOYMENT

If you are self-employed, you need to list the gross income for your business without deducting businessexpenses.

INCOME FROM OTHER SOURCE

List all other income, such as social security, child support, disability, etc.


2018 YTD

2017

2016


2018 YTD

2017

2016

Total Gross Income

Total Gross Income Source

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1. Have you previously filed bankruptcy? If YES, when?

2. Do you have an ownership interest in any business?

If YES, please complete Form 1A: Supplemental Financial Questionnaire for

Self-Employed Persons

3. Are you entitled to receive anything from a divorce or legal separation that

you have not already received?

4. Do you have a judgment of divorce (or dissolution) which requires you to pay

debts owed jointly with your ex-spouse?

5. Are you presently entitled to inherit anything (including life insurance) from

someone who has already died?

6. Do you expect to inherit anything (including life insurance) within one year?

Under some circumstances a person who files bankruptcy may lose his or her

inheritance, even an inheritance that is received after filing bankruptcy. If you

have any reason to believe you will inherit anything, please bring it to the

attention of your attorney.

7. Are you the beneficiary of a trust?

8. In the last ten years have you created a trust or transferred any money or

property into an existing trust?

9. Do you have any burial plots?

10. How much cash do you presently have that is not in the bank?

11. Do you usually have:

more cash than this?

less cash than this?

about this amount of cash?

12. Do you have any other property or any right to receive any property other

than what you have listed in this questionnaire?

If YES, what?

YES NO

YES NO

YES NO

YES NO

YES NO

YES NO

YES NO

YES NO

YES NO

YES NO


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Name of Organization Dates of Donation Amount (or value of items)

13. Do you have any kind of claim or lawsuit pending, or that you believe you can bring against anyone? Examples include personal injury, malpractice, damage to property, money owed, etc.

14. Do you presently have any lawsuit pending against you?

15. Have you been involved in any lawsuits or administrative proceedings in the last year?

16. Other than creditors you have listed, do you know of anyone who you think may bring a lawsuit against you?

17. Have you seen an attorney for any reason in the last four years?

18. Have you been convicted of a crime within the last five years?

If YES, was the crime related to securities fraud?

19. Do you have any criminal charges against you now?

20. Do you owe any money because you caused personal injury to anyone?

21. Do you owe any money because you caused someone’s death?

22. Do you have any debts resulting from drunk driving?

23. Do you have any reason to believe any of your creditors may accuse you of fraud?

24. Do you own or control any items (other than firearms) that are dangerous or hazardous, such as dynamite, dangerous chemicals, or wild animals?

25. In the last year have you repaid any money borrowed from relatives, friends, or business associates?

26. Have you had any wages or bank accounts garnished in the last year?

27. In the last year have you had anything repossessed or foreclosed upon or re-

turned anything to a creditor?

28. Has anyone been appointed by a court to manage your financial affairs?

29. In the last two years, have you made gifts to any one person totaling over $600 in value?

30. In the last two years have you donated money or other items worth over $600 to any one church or other charity? If YES, please specify

YES NO

YES NO

YES NO

YES NO

YES NO

YES NO

YES NO

YES NO

YES NO

YES NO


YES NO

YES NO

YES NO

YES NO

YES NO

YES NO

YES NO

YES NO

YES NO

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31. In the last year, have you had any losses from fires, theft, auto accident, other

casualty or gambling?

32. In the last year, have you made any payments for debt counseling or bankruptcy?

33. In the last two years, have you sold anything, given away anything of value, re-

financed anything, or taken your name off a car title?

34. In the past 4 years, have you owned any real estate you no longer own?

35. In the last year, have you advertised anything for sale on Craigslist, Facebook,

eBay, or other internet sites?

36. Have you posted anything on Facebook or other social media about your financial

condition or about any of your creditors?

37. Do you presently have any safe deposit boxes, or have you had any in the last

year?

38. Do you presently have any storage units, or have you had any in the last year?

39. Do you have in your possession any property that belongs to someone else?

40. Have you ever been cited for violating an environmental or hazardous waste law?

41. Including charges, cash advances, and balance transfers, have you accumulated

more than $1,000 in debt on any one account in the last six months?

42. Including charges, cash advances, and balance transfers, have you accumulated

more than $5,000 in debt on any one account in the last year?

YES NO

YES NO

YES NO

YES NO

YES NO

YES NO

YES NO

YES NO

YES NO

I/We understand that the information provided in this questionnaire will be relied upon by Attorney Milly

Whatley to provide me/us information about debt counseling and bankruptcy.

I/We certify that I/we have completed this form to the best of my/our knowledge and ability, and that the

information contained herein is true and accurate as of the date indicated below.

Print Client Name Client Signature Date

Print Spouse/Domestic Partner Name Spouse/Domestic Partner Signature Date

Please tell us how you found us:

Referral from

Website

Oregon State bar

Other

YES NO

YES NO

YES NO

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