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PERSONAL DATA Last Name: Soc. Sec. No. First and Middle Names: Birth date: (Y/M/D) Are you known by any other name(s): . Please Circle One Mr. / Ms. / Mrs. / Miss Street Address: Telephone: (Home) Town/City: Telephone: (Bus.) State: Zip Code: E-mail address: I have resided at the above address since: Year Month Day I have resided in this state since: Year Month Day Mailing Address (if different): Present Occupation: Full Name and Address of Present Employer: (including zip code) You have been employed since when? Marital Status (Specify month and year of event if it occurred in the last five years, if applicable, for each of the below): Married Y/N Common-law Y/N Single Y/N Widowed Y/N Separated Y/N Divorced Y/N Date of Event: Full name and address of spouse or common-law partner: ______________ Birth date of spouse: Spouse's Soc. Sec. No.: Number of dependents who rely on you for financial support:
PERSONAL DATA List all of your employers, showing dates started and ended, for the past two years
Have you ever been bankrupt? Yes No If yes, give: Filing Date: Location: Date of discharge: Is there a copy available? (please provide copy) Yes No Have you been self-employed in the last five (5) years? Yes No
Names of partners? Place of business (city)? Nature of business? Are you an officer or a director of a limited company? Yes No If yes, give details.
DEBTS List all debts, including secured debts and utilities.
Have any of the above debts arisen from your guarantee or cosigning of debts for another individual or corporation? Yes No If yes, please indicate:
Is borrower bankrupt? Yes No GENERAL 1. Within the last twelve (12) months, have you sold, disposed of or transferred any of your assets? Yes No (e.g.. vehicles, property, stocks/bonds, furniture)
2. Within the last twelve (12) months, have you made payments in excess of regular payments to any creditor? Yes No
3. Within the last twelve (12) 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
5. (a) Please list the banks/financial institutions that you are currently dealing with:
(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).
8. Are you a beneficiary of a will or will you receive 9. Has anyone started legal proceedings against you? Yes No If yes, give details.
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 60 days? Yes No Loans or cash advances in the last 60 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 pretenses/ fraudulent misrepresentation Yes 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.
13. 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
INVENTORY OF ASSETS Name: HOUSEHOLD FURNITURE Address: AND EFFECTS (Garage Sale Value)
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