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10.Do any of your debts arise from:

A fine or penalty imposed by court?Yes No

Credit purchases of luxury goods or services in the last 90 days?Yes No

Loans or cash advances in the last 70 days?Yes No

Debts from willful injury to another person or another person’s property?Yes No

Child Support or Alimony?Yes No

Student loans?Yes No

Recent income tax debts and all other tax debts?Yes No

Fraud, embezzlement, misappropriation?Yes No

Debt for personal injury or death caused by your intoxicated driving?Yes No

Obtaining property by false pretences/

fraudulent misrepresentationYes No

11.For which year did you file your last income tax return?

Did you receive a refund?Yes No

Are there arrears owing?Yes No

Is there a copy available?Yes No

12.Are you paying/receiving any Child support or alimony payments?Yes No

If yes, to/from whom                          Amount since January 1st $

Please provide a copy of the Court Order or separation agreement.

Please provide pay stubs or other evidence of your income for the last 2 months (This MUST be provided in time or the case will be dismissed).

Please provide a copy of a tax return or transcript of a tax return, for the period for which the return was most recently due. (This is required, as your lawyer MUST have this at least 7 days prior to the 341 Meeting).

If you have finished an approved counseling course within the last 6 months please provide the certificate or other proof.  If you have not taken an approved counseling course your lawyer will be able to advise you.

Photo ID MUST be provided.

Please describe briefly, the circumstances that caused your financial difficulties.

I HEREBY CERTIFY THAT THE INFORMATION CONTAINED IN THIS APPLICATION AND ATTACHED INVENTORY SHEET IS A TRUE, CORRECT AND COMPLETE STATEMENT THAT FULLY DISCLOSES THE STATE OF MY ASSETS AND LIABILITIES.

                     Your Signature               Date

BankruptcyAction.com

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