Client Questionnaire Business Form – Fill Out and Use This PDF

Client Questionnaire For Business Debtor

Section 1  Basic Information

Part A. Name and Address

Name of business: _________________________________________________________________

Contact Person’s name: _______________________________________________________________

Telephone Number: _______________ ext.:______Alternative Number: _______________________

Has the business gone by any other names in the past eight years?  No		 Yes	If yes, list other names:
__________________________________________________________________________________
Federal Tax ID or Social Security Number:	_____________________________________________

Address: ___________________________________________________________________________

City: ___________________________		State: _______ Zip: ________________
County:	____________________	Has the business been at this address for at least 180 days?  No  Yes

If there is a different mailing address, please list:

Mailing Address: __________________________________________________________

City: ___________________________ State: _______ Zip: ________________

Part B. Nature of Business

1.Location of principal assets, if different from address above:

______________________________________________________________________________

City: ________________________ State: __________ Zip:__________________________

2.Please describe the nature of your business: _____________________________________________

______________________________________________________________________________

3.	Who is the authorized signer? _____________________ His/Her title?_____________________
4.	Do any of the following describe your business?Railroad	Stockbroker Commodity Broker Clearing bank
	 Health Care Business  Single Asset Real Estate	 501(c)(3) Non-Profit

Part C. Prior/Pending Bankruptcy Cases

1. Has a bankruptcy case been filed by your company or against your company in the last 8 years?  No  Yes If yes, in which district of which state was the case filed? _______________________________

Case Number: ____________________ Date filed: _____________

2.Are there currently any bankruptcy cases pending involving you, your business, your business partner, or any of your

affiliates?  No  Yes

If yes, name of debtor: _______________________________ Relationship to you: __________________

Case Number: _______________ Date filed: _____________ Judge: ______________________

District in which the case was filed: _______________________________

Exhibit "C" to the Voluntary Petition

Does your company own or have possession of any property that poses or is alleged to pose a threat of imminent and identifiable harm to public health or safety?  No  Yes

Client Questionnaire: Copyright©1996-2009 Best Case Solutions

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Part B. Personal Property (Schedule B)

For each type of property listed below, indicate whether the business owns any property of that category, and, if so, fill in the remaining information. You can think of the value as the resale value. Attach additional pages if necessary.

						Office Use Only
	Type of Property		Yes/No	Description & Location	Value	Notes
	1.	Cash on hand
	2.	Checking/Savings
	Account, Certificates of
	deposit, other bank
	accounts

3.Security deposits held by utility companies, landlord

4.Household goods,

furniture, including audio, video, and computer equipment

Client Questionnaire: Copyright©1996-2009 Best Case Solutions

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						Office Use Only
Type of Property			Yes/No	Description & Location	Value	Notes
5.	Books, pictures, art
objects, records, compact
discs, collectibles
6.	Clothing
7.	Furs and jewelry
8.	Sports, photographic,
hobby equipment, firearms
9.	Interest in insurance
policies-specify refund or
cancellation value
10.	Annuities
11.	Interests in an
education IRA, as defined
in 26 USC § 530(b)(1)
12. Interests in pension or
profit sharing plans
13. Stock and interests in
incorporated/
unincorporated business
Client Questionnaire:		Copyright©1996-2009 Best Case Solutions				Page 4

					Office Use Only
Type of Property		Yes/No	Description & Location	Value	Notes
14.	Interests in
partnerships/joint ventures
15.	Bonds
16.	Accounts receivable
17.	Alimony/family
support to which you are
entitled
18.	Other liquidated debts
owed to you, including tax
refunds
19.	Equitable or future
interests or life estates
20.	Interests in estate of
decedent or life insurance
plan or trust
21.	Other contigent/
unliquidated claims,
including tax refunds,
counterclaims
22.	Patents, copyrights,
other intellectual property
23.	Licenses, franchises

Client Questionnaire: Copyright©1996-2009 Best Case Solutions

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