• First Name
• Middle Initial
• Last Name
• Other Names Used in the Last 6 Years
• Street/City Address
• Mailing Address, If Different
• Home Telephone (No Spaces or Dashes)
• Work Telephone (No Spaces or Dashes)
• Email Address

For security reasons, you will not be asked for your SSN at this time.

We will contact you for your SSN as we begin preparation of your petition.

• Give First Names, Ages and Relationships of Relatives Living With You
• Do Any Non-Relatives Live With You? Yes No
• Have You Ever Filed Bankruptcy? Yes No
• If "YES" Give Year and Chapter

All property, other than real estate, is called personal property. Using the definition of value as stated above, fill in the information for each category that applies to you.

• Cash on Hand

Bank Accounts

• Name of Bank
• Balance
• Name of Bank
• Balance
• Name of Bank
• Balance
• Name of Bank
• Balance

Other(Personal)

• Security Deposits w/ Landlords or Utility Companies
• Furniture
• Books/Artwork
• Clothing
• Jewelry
• Firearms - List Each Individually
• Cash Surrender Value of Life Insurance
• Annuities
• Pension/Retirement/401k
• Stocks in Companies (Name & Value)
• Partnership Interests
• Government Bonds
• Money Owed to You
• Name/Address of Person Who Owes You Money
• Description of Debt
• Alimony/Support Owed to You
• Tax Refunds
• Life Estate
• Inheritance You Will Collect in 6 Months or Less
• Claims Where You Could Sue to Collect
• Patents/Copyrights
• Licenses/Franchises

Cars, trucks, trailers, snowmobiles, mobile homes, etc

First Vehicle

• Year
• Make
• Value
• Balance of Loan

Second Vehicle

• Year
• Make
• Value
• Balance of Loan

Third Vehicle

• Year
• Make
• Value
• Balance of Loan

Fourth Vehicle

• Year
• Make
• Value
• Balance of Loan

Boat

• Year
• Make
• Value
• Balance of Loan

Airplane

• Year
• Make
• Value
• Balance of Loan

Other(Business)

• Office Equipment
• Tools Used in Your Business
• Inventory in a Business
• Animals Valued at More Than $500
• Crops
• Farm Equipment
• Farm Supplies
• Other Property (Description & Value)

• If You Have Any Cars, Trucks, Mobile Homes, RVs, Furniture, Etc., Do You Owe Money On Any of Them? Yes No

If "YES", Answer the Following Questions. If "NO", Proceed to Section 8.

First Vehicle

• Vehicle Description
• Name/Address of Lender
• Account#
• Balance of Loan
• Name/Address of Co-Signers, If Any

Second Vehicle

• Vehicle Description
• Name/Address of Lender
• Account#
• Balance of Loan
• Name/Address of Co-Signers, If Any

Third Vehicle

• Vehicle Description
• Name/Address of Lender
• Account#
• Balance of Loan
• Name/Address of Co-Signers, If Any

Fourth Vehicle

• Vehicle Description
• Name/Address of Lender
• Account#
• Balance of Loan
• Name/Address of Co-Signers, If Any

If You Have Any Other Loans That Are Secured By Some Property Not Listed Above (Furniture, etc.), Fill Out the Information Below.

• 1 - Property Description
• Name/Address of Lender
• Account#
• Balance of Loan
• Name/Address of Co-Signers, If Any

• 2 - Property Description
• Name/Address of Lender
• Account#
• Balance of Loan
• Name/Address of Co-Signers, If Any

For All Other Debts (Medical Bills, Credit Cards, Unsecured Loans, etc.) Complete the Following:

1. Name/Address of Creditor
2. Account Number (If Known)
3. Approximate Amount Owing
4. Names of Any Co-Signers

THE BANKRUPTCY COURT REQUIRES THAT YOU LIST EVERY DEBT. THE BANKRUPTCY COURT WILL SEND NOTICES TO YOUR CREDITORS AND WILL USE THE ADDRESSES YOU PROVIDE. YOU MUST GIVE AN ADDRESS FOR EVERY CREDITOR

• Creditors - Name and Address (one per line)
• Have You Charged More Than $1,000 on a Credit Card in the Last 90 Days? Yes No
• If "YES", Give Name/Address of Creditor and Amount Charged
• Have You Obtained an Unsecured Loan in the Last 90 Days? Yes No
• If "YES", Give Name/Address of Lender and Loan Amount
• Have You Signed Any Leases for an Automobile? Yes No
• If "YES", Give Name/Address of Creditor

• How Much Income Have You Received From Working in 2008?
• How Much Income Have You Received From Working in 2007?
• How Much Income Have You Received From Working in 2006?
• Have You Had Any Income From Sources Other Than Working in the Past 2 Years? Yes No
• If "YES", List Source and Amount for Each Year
• Not Including Car or House Payments, Have You Paid More Than $600 to Any Single Creditor in the Last 90 Days? Yes No
• If "YES", Give Name/Address of Creditor and Amount Paid
• Have You Repaid Any Loans From a Relative in the Last Year? Yes No
• If "YES", Give Name/Address, Date of Payment and Amount Paid
• Has Anyone Sued You in the Last Year? Yes No
• If "YES", Give Name of Person Who Sued, Name/Address of Their Attorney and Case# of Lawsuit
• Has Anyone Garnished Your Wages or Bank Account in the Last 90 Days? Yes No
• If "YES", Give Name of Creditor, Date of Garnishment and Amount Garnished
• Has Anything Been Repossessed by or Returned to a Creditor in the Last Year? Yes No
• If "YES", Give Name/Address of Creditor, Description of Item Repossessed or Returned and Date
• In the Last 120 Days, Have You Given Any Property to a Creditor to Use as Collateral for a Loan? Yes No
• If "YES", Give Name/Address of Creditor, Description and Value of Property and Date
• Has Any of Your Property Been Under the Control of a Custodian, Receiver or Court Appointed Official in the Last Year? Yes No
• If "YES", Give Name/Address of Custodian, Name of Court, Description of Property and Date
• Have You Made Any Gifts to a Charity (Church, etc.) of More Than $100 in the Last Year? Yes No
• If "YES", Give Name of Charity, Date and Amount of Gift
• Have You Made Gifts to Family Members During the Last Year of More Than $200? Yes No
• If "YES", Give Name/Address of Person Who Received Gift, Date and Amount of Gift
• Have You Suffered Any Losses from Fire, Theft or Gambling in the Last Year? Yes No
• If "YES", Describe Loss and Date of Loss
• Other Than Payments to Dale L. Smith at Oregon Fresh Start for Help With This Current Bankruptcy, Have You Made Any Payments or Transferred Any Property (Including Money) to Anyone for Consultation Concerning Debt Consolidation or Help With a Bankruptcy Petition? Yes No
• If "YES", Give Name/Address of Person/Organization, Date and Amount of Payment
• Have You Sold, Bartered or Transferred Any Property in the Last Two Years? Yes No
• If "YES", Give Name/Address of Person Who Received Property, Description and Value of Property, and Date of Transfer
• Have You Closed Any Bank Accounts in the Last Year? Yes No
• If "YES", Give Name of Bank, Date of Closure and Account Balance at Time of Closing
• Do You Now Have or Have You Had in the Last Year a Safe Deposit Box? Yes No
• If "YES", Give Name of Bank and Contents of Box
• If Any of Your Creditors Also Owed You Money in the Last Year, Did You Agree With the Creditor to Just Cancel Both Debts Rather Than Pay Each Other Money? Yes No
• If "YES", Give Name/Address of Creditor and Description of Transaction
• Do You Have in Your Possession or Do You Control Any Property That Belongs to Another Person? Yes No
• If "YES", Give Name/Address of Other Person and Description of Property
• Have You Moved in the Last 2 Years? Yes No
• If "YES", Give Addresses and Dates You Lived There
• Within the Last 6 Years, Have You Lived in Alaska, Arizona, California, Idaho, Louisiana, Nevada, New Mexico, Puerto Rico, Texas, Washington or Wisconsin with a Spouse? Yes No
• If "YES", Give Dates and Places
• Has Any Governmental Agency Given You Any Written Notice That You May Have Violated an Environmental Law Pertaining to Pollution, Hazardous Waste or Groundwater Contamination? Yes No
• If "YES", Give Address of Location, Date of Notice and Name of Governmental Agency
• Have You Given Any Notice to a Governmental Agency Where You Admitted That You Released a Hazardous Material? Yes No
• If "YES", Give Name of Governmental Agency, Date of Notice and Location of Site
• Have You Been a Party to Any Court or Administrative Proceeding Involving a Violation of an Environmental Law? Yes No
• If "YES", Give Name and Date of Proceeding
• Have You Been Involved as an Officer, Director, Partner or Managing Executive of a Corporation, Partnership or Sole Proprietorship in the Last 6 Years? Yes No
• If "YES", Give Name/Address of Business and Taxpayer ID# of Business
• Within the Last 6 Years, Have You Owned More Than 5% of a Corporation? Yes No
• If "YES", Give Name of Corporation and Dates of Ownership
• Have You Been Involved as an Owner of a Business Within the Last 2 Years? Yes No

• If "YES", Answer the Following Questions

• Name of Business
• Business Address
• Nature of Business
• Beginning of Date
• Is the Business Still Operating? Yes No
• If "NO", Give Date Closed
• Name Any Bookkeepers or Accountants Who Assisted with Record keeping of Business
• Name of Bank or Creditor Who Was Given Any Financial Statement in the Last 2 Years
• If Business Was/Is a Partnership, Give Names of Other Partners