Form Preview Example

(If yes, please attach a list and description of the property.)

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

Page 1

Section 2  Property

Part A. Real Estate (Schedule A)

List all real estate which the business owns or is a joint owner of, even if the business still owes money on the property.

Address and description of property

Value

The	List all mortgages and liens
business’s %
ownership, or
$ amount of	What is the $
equity, if your	value of the	Who issued the lien, loan or mortgage? (name
business is not	loan, lien, or	and address of institution)
the sole	mortgage?
owner.

Office Use Only

Notes

Page 2

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

Page 3

						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

Page 5

					Office Use Only
Type of Property		Yes/No	Description & Location	Value	Notes
24.	Customer list or other
compilation with
personally identifiable
information

25.	Automobiles, trucks,
trailers, and accessories.

26.	Boats, motors, and
accessories

27.	Aircraft and
accessories

28.	Office equipment,
supplies

29.	Machinery, fixtures
etc. for business

30.	Inventory

31.	Animals

32.	Crops-growing or
harvested

33.	Farming equipment
and implements

34.	Farm supplies,
chemicals, feed

Page 6

Type of Property

Yes/No

Description & Location

35.Other personal property of any kind not listed.

Value

Office Use Only

Notes

Page 7

Section 3  Debts

List below all debts that the business owes, or that creditors claim that the business owes. Attach additional sheets if necessary.

Office Use Only

Creditor Name and Address

What is the debt for?

Is there a codebtor,

Do you

Notes:

2. Date/Range of dates when debt was incurred

Describe the collateral for this

someone else who can

lawsuit

Amount

dispute

3. Account Number, if any

loan, if any. What is the

be held responsible for

Sched.

pending?

owed

the

4. Contact person’s name and address, if

estimated value of the

the debt? If so, his/her

D, E

Collection

debt?

Type of

different

collateral?

name and address:

or F?

agency or

Debt

attorney

assigned?

Mortgages

Car/vehicle

loans

Other bank

loans

Page 8

Office Use Only

Creditor Name and Address

What is the debt for?

Is there a codebtor,

Do you

Notes:

2. Date/Range of dates when debt was incurred

Describe the collateral for this

someone else who can

lawsuit

Amount

dispute

3. Account Number, if any

loan, if any. What is the

be held responsible for

Sched.

pending?

owed

the

4. Contact person’s name and address, if

estimated value of the

the debt? If so, his/her

D, E

Collection

debt?

Type of

different

collateral?

name and address:

or F?

agency or

Debt

attorney

assigned?

Personal

(non-bank)

loans

Major

credit card

debts

(Visa, Am

Ex,

Mastercard,

Discover)

Department

store or

other

store-issued

credit card

debts

Page 9

Office Use Only

Creditor Name and Address

What is the debt for?

Is there a codebtor,

Do you

Notes:

2. Date/Range of dates when debt was incurred

Describe the collateral for this

someone else who can

lawsuit

Amount

dispute

3. Account Number, if any

loan, if any. What is the

be held responsible for

Sched.

pending?

owed

the

4. Contact person’s name and address, if

estimated value of the

the debt? If so, his/her

D, E

Collection

debt?

Type of

different

collateral?

name and address:

or F?

agency or

Debt

attorney

assigned?

Other credit

card debts

(Gas cards,

phone

cards, etc.)

Unpaid

utility bills

Unpaid rent

Page 10

Office Use Only

Creditor Name and Address

What is the debt for?

Is there a codebtor,

Do you

Notes:

2. Date/Range of dates when debt was incurred

Describe the collateral for this

someone else who can

lawsuit

Amount

dispute

3. Account Number, if any

loan, if any. What is the

be held responsible for

Sched.

pending?

owed

the

4. Contact person’s name and address, if

estimated value of the

the debt? If so, his/her

D, E

Collection

debt?

Type of

different

collateral?

name and address:

or F?

agency or

Debt

attorney

assigned?

Unpaid

taxes

Unpaid

service fees

(to

attorneys,

accountants

etc.)

Trade Debts

Page 11

Office Use Only

Creditor Name and Address

What is the debt for?

Is there a codebtor,

Do you

Notes:

Date/Range of dates when debt was incurred

Describe the collateral for this

someone else who can

lawsuit

Amount

dispute

Account Number, if any

loan, if any. What is the

be held responsible for

Sched.

pending?

owed

the

Contact person’s name and address, if

estimated value of the

the debt? If so, his/her

D, E

Collection

debt?

Type of

different

collateral?

name and address:

or F?

agency or

Debt

attorney

assigned?

All other unpaid debts/bills

Page 12

Section 4  Unexpired Leases and Contracts (Schedule G)

List below any leases or contracts that are still current that the business is a party to. Include real estate, car and business leases, and service or business contracts.

Nature and Description of Contract	Name and Address of Other Party or Parties	Date that Contract Expires

Page 13

Section 5  Statement of Financial Affairs

If you have no information to report for a question, check the "NONE" box.

1.Income from employment or operation of business

State your gross income from employment or operation of a business: If you have not received an income from employment during the two years immediately preceding this calendar year, check this box:

NONE

Period

$ Amount

Source

January 1 of this year through date of commencement of case

Last year, (January 1 - December 31)

The year before last, (January 1 - December 31)

2.Income other than from employment or operation of business

State the amount of income received other than from employment or operation of business during the two years immediately preceding the commencement of this case:

NONE

Period	$ Amount	Source
During the last year
Year before last

3.Payments to creditors

a. If your debts are primarily consumer debts, List all payments on loans, installment purchases of goods or services, and other debts, aggregating more than $600 to any creditor made within 90 days immediately preceding the commencement of this case. Indicate with an asterisk (*) any payments that were made on account of a domestic support obligation, or that were made as part of an alternative payment plan.

NONE

Name and Address of Creditor

Dates of Payments

Amount paid

Amount still owed

Page 14

b.If your debts are not primarily consumer debts, list each payment or other transfer, aggregating more than $5,475 to any creditor within 90 days immediately preceding the commencement of this case.

NONE

Name and Address of Creditor

Dates of Payments

Amount paid

Amount still owed

c.All debtors. List all payments made within one year immediately preceding the commencement of this case to or for the benefit of creditors who are or were "insiders". ("Insiders" include your relatives, your business partners and their relatives, your corporations, or your affiliates.)

 NONE
Name and Address of Creditor
and Relationship to You	Dates of Payments	Amount Paid	Amount Still Owed

4.Suits, executions, garnishments and attachments

a. List all suits and administrative proceedings to which you are or were a party within one year preceding the filing of this case.

 NONE
Caption of Suit	Court or Agency	Status or
and Case Number Nature of Proceeding	and Location	Disposition

b.Describe all property that has been garnished, seized, or attached under any legal or equitable process within one year immediately preceding the commencement of this case.

 NONE
Name and Address of Person/Company		Description
for Whom the Property Was Seized (Creditor)	Date of Seizure	and Value of Property

Page 15

5. Repossessions, foreclosures, and returns

List all property that has been repossessed by a creditor, sold at a foreclosure sale, transferred through a deed in lieu of foreclosure, or returned to the seller, within one year immediately preceding the commencement of this case.

 NONE
	Date of Repossession,	Description
Name and Address of Creditor	Foreclosure, Transfer or Return	and Value of Property

6.Assignments and receiverships

a.Describe any assignment of property for the benefit of creditors made within 120 days immediately preceding the commencement of this case.

NONE

Name and Address of Assignee

Date of Assignment

Terms of Assignment/Settlement

b.List all property which has been in the hands of a custodian, receiver, or court-appointed official within one year immediately preceding the commencement of this case.

 NONE
Name and Address	Name and location of Court,	Date of	Description and Value
of Custodian	Case Title and Number	Order	of Property

7. Gifts

List all gifts or charitable contributions made within one year immediately preceding the commencement of this case except ordinary and usual gifts to family members aggregating less than $200 in value per individual family member and charitable contributions aggregating less than $100 per recipient.

 NONE
Name and Address		Date	Description
of Recipient	Relationship to You, if Any	of Gift	and Value of Gift

Page 16

8.Losses

List all losses from fire, theft, gambling or other casualty within one year immediately preceding the commencement of this case or since the commencement of this case.

 NONE
Description and Value	Description of Circumstances and
of Property	Amount Covered by Insurance, if Any	Date of Loss

9.Payments related to debt counseling or bankruptcy

List all payments made or property transferred by or on behalf of the debtor to any persons, including attorneys, for consultation concerning debt consultation, relief under the bankruptcy law or preparation of the petition in bankruptcy within one year immediately preceding the commencement of the case.

 NONE
Name and Address	Date of	Name of Person	Amount of Money/ Description
of Payee	Payment	Who Paid, if Not You	and Value of Property

10.Other transfers, (including sale of your property)

a. List all other property, other than property transferred in your ordinary course of business or financial affairs, transferred either absolutely or as a security within two years immediately preceding the commencement of this case.

 NONE
Name and Address of Transferee		Description of Property
and Relationship to you	Date of Transfer	Transferred and Value Received

b. List all property transferred within 10 years immediately preceding the commencement of this case to a self-settled trust, or similar device of which the debtor is the beneficiary.

 NONE
Name of Trust or		Amount of Money or Description
Similar Device	Date of Transfer	and Value of Property or Interest

11. Closed financial accounts

List all financial accounts and instruments held in your name or for your benefit which were closed, sold, or otherwise transferred within one year immediately preceding the commencement of this case.

	 NONE
	Name and Address	Type and Number of	Amount and Date
	of Institution	Account & Final Balance	of Sale or Closing
Client Questionnaire: Copyright©1996-2009 Best Case Solutions			Page 17

12. Safe deposit boxes

List each safe deposit or other box or depository in which you have or have had securities, cash, or other valuables within one year immediately preceding commencement of this case.

 NONE
Name and Address of	Name and Address of Those	Description	Date of
Bank or Other Depository	With Access to Box or Depository	of Contents	Transfer, if Any

13.Setoffs

List all setoffs made by any creditor, including a bank, against a debt or deposit of yours within 90 days preceding the commencement of this case.

NONE

Name and Address of Creditor

Date of Setoff

Amount of Setoff

14.Property held for another person

List all property that you hold or control that is owned by another person.

NONE

Name and Address of Owner

Description and Value of Property

Location of Property

15.Prior address of debtor

If you have moved within the three years immediately preceding the commencement of this case, list all residences during the last three years, excluding your present address.

NONE

Address

Your Name at the Time

Dates of Occupancy

16. Spouses and Former Spouses

If you reside or resided in a community property state, commonwealth, or territory (including Alaska, Arizona, California, Idaho, Louisiana, Nevada, New Mexico, Puerto Rico, Texas, Washington, or Wisconsin) within the eight-year period immediately preceding the commencement of the case, identify the name of your spouse and of any former spouse who resides or resided with you in the community property state.

NONE

Name

Page 18

17.Environmental Information.

For the purpose of this question, the following definitions apply:

"Environmental Law" means any federal, state, or local statute or regulation regulating pollution, contamination, releases of hazardous or toxic substances, wastes or material into the air, land, soil, surface water, groundwater, or other medium, including, but not limited to, statutes or regulations regulating the cleanup of these substances, wastes, or material.

"Site" means any location, facility, or property as defined under any Environmental Law, whether or not presently or formerly owned or operated by the debtor, including, but not limited to, disposal sites.

"Hazardous Material" means anything defined as a hazardous waste, hazardous substance, toxic substance, hazardous material, pollutant, or contaminant or similar term under an Environmental Law

a. List the name and address of every site for which you received notice in writing by a governmental unit that it may be liable or potentially liable under or in violation of an Environmental Law. Indicate the governmental unit, the date of the notice, and, if known, the Environmental Law:

 NONE
	Name and Address of	Date	Environmental
Site Name and Address	Governmental Unit	of Notice	Law

b. List the name and address of every site for which you provided notice to a governmental unit of a release of Hazardous Material. Indicate the governmental unit to which the notice was sent and the date of the notice.

 NONE
	Name and Address of	Date	Environmental
Site Name and Address	Governmental Unit	of Notice	Law

c. List all judicial or administrative proceedings, including settlements or orders, under any Environmental Law with respect to which you are or were a party. Indicate the name and address of the governmental unit that is or was a party to the proceeding, and the docket number.

 NONE
Name and Address of
Governmental Unit	Docket Number	Status or Disposition

Page 19

18.Nature, location and name of business

a. If the debtor is an individual, list the names, addresses, taxpayer identification numbers, nature of the businesses, and beginning and ending dates of all businesses in which the debtor was an officer, director, partner, or managing executive of a corporation, partnership, sole proprietorship, or was a self-employed professional within the six years immediately preceding the commencement of this case, or in which the debtor owned 5 percent or more of the voting or equity securities within the six years immediately preceding the commencement of this case.

If the debtor is a partnership, list the names, addresses, taxpayer identification numbers, nature of the businesses, and beginning and ending dates of all businesses in which the debtor was a partner or owned 5 percent or more of the voting or equity securities, within the six years immediately preceding the commencement of this case.

If the debtor is a corporation, list the names, addresses, taxpayer identification numbers, nature of the businesses, and beginning and ending dates of all businesses in which the debtor was a partner or owned 5 percent or more of the voting or equity securities within the six years immediately preceding the commencement of this case.

NONE

	Taxpayer		Beginning and End
Name	I.D. Number(EIN) Address	Nature of Business	Dates of Operation

b. Identify any business listed in response to subdivision a., above, that is "single asset real estate" as defined in 11 U.S.C. § 101.

NONE

NameAddress

Page 20

The following questions, #19-25, are only to be answered if you are a corporation or partnership or if you have been, in the six years immediately preceding this case, an officer, director, managing executive, or owner of more than 5% of the voting securities of the corporation; a partner, other than a limited partner, of a partnership; a sole proprietor, or otherwise self-employed.

19.Books, records, and financial statements

a.List all bookkeepers and accountants who, within the two years immediately preceding the filing of this bankruptcy case, kept or supervised the keeping of books of account and records.

NONE

Name and Address

Dates Services Rendered

b.List all firms or individuals who, within the two years immediately preceding the filing of this bankruptcy case, have audited the books of account and records, or prepared a financial statement of the debtor.

NONE

Name

Address

Dates Services Rendered

c.List all firms or individuals who, at the time of the commencement of this case, were in possession of your books of account and records. If the records are not available, explain.

NONE

Name and Address

Comments

d.List all financial institutions, creditors and other parties, including mercantile and trade agencies, to whom a financial statement was issued by the debtor within two years immediately preceding the commencement of this case.

NONE

Name and Address

Date Issued

Page 21

20.Inventories

a.List the dates of the last two inventories taken of your property, the name of the person who supervised the taking of each inventory, and the dollar amount and basis of each inventory.

NONE

		Dollar Amount of Inventory
Date of Inventory	Inventory Supervisor	(specify cost, market, or other basis)

b.List the name and address of the person possessing the records of each of the two inventories reported in a.) above.

NONE

Date of Inventory

Name and Address of Custodian of Inventory Records

21.Current partners, officers, directors, and shareholders

a.If your business is a partnership, list the nature and percentage of partnership interest of each member of the partnership.

NONE

Name and Address

Nature of Interest Percentage of Interest

b.If your business is a corporation, list all officers and directors of the corporation, and each stockholder who directly or indirectly owns, controls, or holds 5 % or more of the voting securities of the corporation.

NONE

		Nature and Percentage
Name and Address	Title	of Stock Ownership

22.Former partners, officers, directors and shareholders

a.If your business is a partnership, list each member who withdrew from the partnership within one year immediately preceding the commencement of this case.

NONE

Name and Address

Date of Withdrawal

Page 22

b.If your business is a corporation, list all officers or directors whose relationship with the corporation terminated within one year immediately preceding the commencement of this case.

NONE

Name and Address

Title

Date of Termination

23.Withdrawals from a partnership or distributions by a corporation

If your business is a partnership or corporation, list all withdrawals or distributions credited or given to an insider, including compensation in any form, bonuses, loans, stock redemptions, options exercised and any other perquisite during one year immediately preceding the commencement of this case.

 NONE
Name and Address of	Date and Purpose	Amount of Money or Description
	Recipient, and Relationship to You		of
Withdrawal	and Value of Property

24.Tax Consolidation Group.

If the debtor is a corporation, list the name and federal taxpayer identification number of the parent corporation of any consolidated group for tax purposes of which the debtor has been a member at any time within the six-year period immediately preceding the commencement of the case.

NONE

Name of Parent Corporation

Taxpayer Identification Number

25.Pension Funds.

If the debtor is not an individual, list the name and federal taxpayer identification number of any pension fund to which the debtor, as an employer, has been responsible for contributing at any time within the six-year period immediately preceding the commencement of the case.

NONE

Name of Pension Fund

Taxpayer Identification Number

Page 23

Section 6  Supplement for Chapter 11 Cases

Part A. Exhibit "A" to Voluntary Petition

If debtor is required to file periodic reports (e.g. - Forms 10K and 10Q) with the Securities and Exchange Commission pursuant to Section 13 or 15(d) of the Securities Exchange Act of 1934 and is requesting relief under chapter 11 of the Bankruptcy code, Exhibit "A" shall be completed and attached to the petition.

Are any of your securities registered under section 12 of the Securities Exchange Act of 1934?  Yes  No If so, what is the SEC file number? _______________________

The following questions ask for financial data about your company. Your answers reflect the company’s finances as of (date) _________________.

Total assets: $__________________

Total liabilities: $_________________

Please list debt securities held by more than 500 holders

Approximate number of holders

 Secured	 Unsecured	 Subordinated$
 Secured	 Unsecured	 Subordinated$
 Secured	 Unsecured	 Subordinated$
 Secured	 Unsecured	 Subordinated$
 Secured	 Unsecured	 Subordinated$

Number of shares of preferred stock

Number of shares of common stock

Comments, if any:

Briefly describe the nature of your business:

List the name of any person who directly or indirectly owns, controls, or holds, with power to vote, 5% or more of the voting securities of your company:

Page 24

Part B. Equity Security Holders

List the names and addresses of all equity security holders:

Name and Address

Security Class

Number of Securities

Kind of Interest

Page 25

Question	Answer
Form Name	Client Questionnaire Business Form
Form Length	25 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	6 min 15 sec
Other names	schedule c 2018 questionner for client, questionnaire for wedding client questionnaire, questionaire for clients, assessment questionnaire client bookkeeping

Client Questionnaire Business Form – Fill Out and Use This PDF

Client Questionnaire Business Form PDF Details

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Client Questionnaire Business Form – Fill Out and Use This PDF

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