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Have any of the above debts arisen from your guarantee or co-signing

of debts for another individual or corporation? Yes No

If yes, please indicate:

Lender's Name

Lender's Address

Amount

Borrower's Name

Borrower's Address

Is borrower bankrupt?Yes No

GENERAL

1.Within the last twenty-four (24) months, have you sold, disposed of or

transferred any of your assets? Yes No

(eg. vehicles, property, stocks/bonds, furniture)

Description

of Asset

Date

Disposed

To Whom

Proceeds

Disposition

of Proceeds

2.Within the last twenty-four  (24) months, have you made payments in excess

of regular payments to any creditor? Yes No

3.Within the last twenty-four (24) months, have you had any assets seized

by a creditor? Yes No

If yes, provide details

Asset seized

Date seized

Name of party seized by

Was party who made seizure a secured creditor?Yes No

Form of security?

4.Do you expect to receive any sums of money, or any other property within the next

12 months, which are not related to your normal income?Yes No

BankruptcyAction.com

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