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5.(a)Please list the banks that you are currently dealing with:

Bank

Address

City

Zip

Code

Amount

Currently

In Account

(b)Do you have a safety deposit box? Yes No

If so, which bank?

Please provide details of the contents:

6.Does anyone owe you any money?  Provide details. Yes No

(a)Personal loans

(b)Accounts receivable

(c)Agreement for sale

(d)Other

7.Do you currently own any of the following?

(a)Collectibles (stamps, coins, art, antiques, etc.) Yes No

(b)Savings bonds (owned presently or being purchased

on a payroll savings plan).Yes No

(c)Shares (owned presently or being purchased on a

payroll savings plan).Yes No

Please provide details

(d)Personal life insurance policies (please include Yes No

a copy of your life insurance policy).

Policy No. 1

Policy No. 2

i)Life Insurance Company

ii)Beneficiary

iii)Cash Surrender Value

8.Are you a beneficiary of a will or will you receive

an inheritance?Yes No

9.Has anyone started legal proceedings against you?Yes No

If yes, give details.

BankruptcyAction.com

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