Today's Date:
1 . Are you Married? Yes No
2. Have you ever filed for Bankruptcy? Yes No If so, when?
3. Debtor’s First Name: Middle: Last:
4. Co-Debtor’s First Name: Middle: Last:
5. Debtor’s SS #:
6. Co-debtor’s SS #:
7. Debtor’s Birth Date:
8. Co-debtor’s Birth Date:
9. Home #:
10. Debtor’s Work #:
11. Co-Debtor’s Work #:
12. Debtor’s Cell #:
13. Co-Debtor’s Cell #:
14. What is your address?
Street: Zip Code:
County/City:

Schedule A
15. How many properties do you own?

First Property:
Single Family Rowhome Townhome Condo Duplex/Semi
Street: Zip Code:
County/City:
Whose Name(s) is on the Deed?
Purchase Price $ Year Purchased: Number of Mortgages:
(1st) Mortgage Company: Payment per month: $
How much do you owe total?:$ How many months are you behind? Payment Due Date?
(2st) Mortgage Company: Payment per month: $
How much do you owe total?:$ How many months are you behind? Payment Due Date?

Second Property:
Single Family Rowhome Townhome Condo Duplex/Semi
Street: Zip Code:
County/City:
Whose Name(s) is on the Deed?
Purchase Price $ Year Purchased: Number of Mortgages:
(1st) Mortgage Company: Payment per month: $
How much do you owe total?:$ How many months are you behind? Payment Due Date?
(2st) Mortgage Company: Payment per month: $
How much do you owe total?:$ How many months are you behind? Payment Due Date?

B. Personal Property (Schedule B)

1. Any Cash on Hand: Yes No $
2. Any Checking/Savings Accounts: Yes No
Bank & Location:
Account Balance (at end of month)$
Checking/Savings Account Bank & Location:
Account Balance (at end of month)$
3. Any Security Deposits: Yes No Amt $
With Whom? (Ex., Landlord, BGE):
4. Any Insurance Policies: Yes No ; Is it Term Universal Whole Life
Cash Surrender Value (Whole Life Only) $
5. Any Pensions: Yes No ; Is it a 401K Gov't Pensions SEP DeferredComp
What is it worth? $
6. Any Bonds: Yes No ; Number of w/ face value of $
7. Receiving a Tax Refund for 2004: Yes No ; State $ Federal $
8. Do you have/had any interest in any Business or are you self-employed? Yes No
Name: Kind of Bus: Address:
Date Started and Ended: Incorporated or Sole Proprietor:
9. Any Lawsuits/Claims for Personal Injury, WCC, Medical Malpractice, Contract? Yes No ;
Date of Injury: ; Lawyer handling case:
10. Do you own any or are you buying any vehicles? Yes No

1st Automobile:
Year Make Model Mileage
Name(s) on Title
Car Loan Co. : Payment per month$ Due Date?
How much do you owe total?$ ; Months behind
Name(s) on Loan:

2nd Automobile:
Year Make Model Mileage
Name(s) on Title
Car Loan Co. : Payment per month$ Due Date?
How much do you owe total?$ ; Months behind
Name(s) on Loan:

11. Please fill out the attached list of personal property to the best of your ability.
List Items owned by both Debtor and C-debtor only once.

Other Valuable Personal Property:

C. Priority Creditors (Schedule E)

Have you filed all your taxes returns? Yes No Do you owe Income Taxes? Yes No
What years do you owe for?
If yes, how much do you owe the IRS $
State of MD $

D. Loans (Schedule D or F)

Do you have any loans with the SECU, MECU or some other Credit Union? Yes No
If Yes, what bank is the loan with?
If Yes, are there any co-signors on the loan? Yes No
First Co-Signer
Name:
Address: City,State, Zip:

Second Co-Signer
Name:
Address: City,State, Zip:

E. Current Income: Monthly Income (Schedule I)

Are you: Married Separated Divorced Single Widowed
Debtor’s occupation?: Co-Debtor’s Occupation:
Debtor’s employer?: Co-Debtor’s Employer:
Debtor’s length of employ: Co-Debtor’s length of employ?:
Debtor’s take home pay $ Co-Debtor’s take home pay $
Debtor paid: Biweekly Weekly Monthly
Co-Debtor paid: Biweekly Weekly Monthly
Do you have any other sources of income in your household? Yes No
What type is it? (Ex, Social Security, Alimony, Child Support, Government Assistance)
1. ; 2.
How much do you receive per month? $ ; $
What was your Gross Household Income for the following years (approximately)
2005 $ ; 2004 $ ; 2003 $
Is anyone garnishing your wages? Yes No Who? Debtor/Co-Debtor
Case Name: Case Number: Court:

Is anyone suing you or are there any judgments entered against you? Yes No
Please provide details: What Court:
1.Case Name: 1.Case Number:
2.Case Name: 2.Case Number:
3.Case Name: 3.Case Number:
Dependents:
Do you have any Dependents that you claim on your tax returns? Yes No
1st dependent‘s name: age: - Does the dependent live with you? Yes No
2nd dependent‘s name: age: - Does the dependent live with you? Yes No
3rd dependent‘s name: age: - Does the dependent live with you? Yes No

F. Monthly Expenses (Schedule J)

1. Your rent or your home mortgage: $
2. Electricity and heating: $
3. Telephone service/long distance: $
4. Do you have any other utility bills? Yes No If so, what and how much per month? $
5. Medical and dental expenses: $
6. Insurance not deducted from paycheck
a) homeowner’s or renter’s insurance: $
b) life insurance: $
c) health insurance: $
d) auto insurance $
e) other insurance : $
7. Car Payment: $
8. Alimony, maintenance, support paid to others: $
9. Payments for support of dependents not living at home: $
10. Other expenses not listed above:
a) $
b) $
c) $

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