Intake Checklist for Official Form 101 - Voluntary Petition for Individuals

Worksheet only. Transfer this data into the official Form 101 or e-filing software. Do not place full SSNs here; use last 4 only and file Official Form 121 for full SSNs.

United States Bankruptcy Court
District of [District]
Case No.: [To be assigned]
Chapter requested: [7/11/13]
Joint case? [Yes/No]

Part 1: Debtor Information

• Debtor 1: Full name [ ], SSN last 4 [####], Street [ ], County [ ], Mailing (if different) [ ].
• Debtor 2 (if joint): Full name [ ], SSN last 4 [####], Street [ ], County [ ], Mailing (if different) [ ].
• All prior names in last 8 years (both debtors): [List].
• Business names/EINs used in last 8 years (if any): [List/EIN last 4].

Part 2: Venue

• Basis: [Residence / Principal place of business / Principal assets] in this district.
• District of residence for past 180 days: [ ].

Part 3: Prior/Pending Cases

• Prior bankruptcy cases (8-year lookback): Case No./District/Filing Date [ ].
• Pending cases of spouse/affiliate/partner: [ ].

Part 4: Chapter Selection and Nature of Debts

• Chapter: [7/11/13].
• Nature of debts: [Consumer / Business / Mixed].

Part 5: Statistical Estimates (official ranges)

• Estimated assets (check one):
• [ ] $0–$50,000
• [ ] $50,001–$100,000
• [ ] $100,001–$500,000
• [ ] $500,001–$1,000,000
• [ ] $1,000,001–$10,000,000
• [ ] $10,000,001–$50,000,000
• [ ] $50,000,001–$100,000,000
• [ ] $100,000,001–$500,000,000
• [ ] $500,000,001–$1,000,000,000
• [ ] More than $1,000,000,000
• Estimated liabilities (check one): same ranges as above.
• Estimated number of creditors (check one):
• [ ] 1–49 [ ] 50–99 [ ] 100–199 [ ] 200–999 [ ] 1,000–5,000 [ ] 5,001–10,000 [ ] 10,001–25,000 [ ] 25,001–50,000 [ ] 50,001–100,000 [ ] More than 100,000

Part 6: Credit Counseling

• Completed briefing within 180 days before filing? [Yes/No]
• If no, request for waiver/exigent circumstances? [Yes/No] (describe).
• Provider and date of briefing: [ ].

Part 7: Payments/Assistance/Attorney

• Paid or agreed to pay an attorney for this case? [Yes/No] (name/address/fee disclosure).
• Paid anyone to help prepare documents? [Yes/No] (name/address).
• Bankruptcy petition preparer involved? [Yes/No].

Part 8: Other Required Declarations (mirror official prompts)

• Do you operate a business? [Yes/No] (describe).
• Any property posing imminent health/safety threat? [Yes/No] (describe).
• Prior 1 year: transfers to insiders/self-settled trusts? [Yes/No] (describe).
• Health care business? [Yes/No].
• Single asset real estate debtor? [Yes/No].

Part 9: Signatures

I request relief in accordance with the chapter of Title 11 specified above. I declare under penalty of perjury that the information provided is true and correct.

Debtor 1 Signature: __________________________ Date: __________
Debtor 2 Signature (if joint): __________________________ Date: __________

Attorney (if any)
Name/Bar No.: [Name, Bar No.]
Firm/Address/Phone/Email: [Details]
Signature: __________________________ Date: __________

Bankruptcy Petition Preparer (if any)
Name/Address: [ ]
Certification of compliance with 11 U.S.C. §110; fee disclosed.
Signature: __________________________ Date: __________

Transfer all entries to official Form 101; file Form 121 for full SSNs; attach credit counseling certificate and any district-required exhibits.