Form 107 Worksheet - Statement of Financial Affairs for Individuals

Worksheet only. Not the official form. Transfer all entries to the official Form 107 or e-filing software. Question order mirrors the current form; confirm the version you file.

United States Bankruptcy Court
District of [District]

In re: [Debtor Name(s)]
Case No.: [if known]
Chapter: [7/11/13]
Check if amended filing: [Yes/No]

Part 1: Tell the Court About Yourself

1. Current marital status: [Married / Not married]
2. Other addresses in last 3 years? [No / Yes - list below]
   | Debtor | Address (Number/Street/City/State/ZIP) | Dates lived there (From/To) |
   | --- | --- | --- |
   | Debtor 1 | [ ] | [ ] |
   | Debtor 2 | [ ] | [ ] |
3. Community property state or territory in last 8 years with spouse or legal equivalent? [No / Yes]
   Community property states/territories include Arizona, California, Idaho, Louisiana, Nevada, New Mexico, Puerto Rico, Texas, Washington, Wisconsin.
   If yes, complete Schedule H (Form 106H) and list the state/territory: [ ].

Part 2: Explain the Sources of Your Income

4. Income from employment or operating a business (current year to filing date and prior 2 calendar years). [No / Yes]
   If joint income, list once under Debtor 1.
   | Period | Debtor | Wages/commissions/bonuses/tips (check) | Operating a business (check) | Gross income |
   | --- | --- | --- | --- | ---: |
   | Current year to filing date | Debtor 1 | [ ] | [ ] | $[ ] |
   | Current year to filing date | Debtor 2 | [ ] | [ ] | $[ ] |
   | Last calendar year | Debtor 1 | [ ] | [ ] | $[ ] |
   | Last calendar year | Debtor 2 | [ ] | [ ] | $[ ] |
   | Year before last | Debtor 1 | [ ] | [ ] | $[ ] |
   | Year before last | Debtor 2 | [ ] | [ ] | $[ ] |
5. Other income (all other sources; include alimony, child support, Social Security, unemployment, public benefits, pensions, rental income, interest, dividends, lawsuit proceeds, royalties, gambling/lottery). [No / Yes]
   List each source separately.
   | Period | Debtor | Source of income | Gross income |
   | --- | --- | --- | ---: |
   | Current year to filing date | Debtor 1 | [ ] | $[ ] |
   | Current year to filing date | Debtor 2 | [ ] | $[ ] |
   | Last calendar year | Debtor 1 | [ ] | $[ ] |
   | Last calendar year | Debtor 2 | [ ] | $[ ] |
   | Year before last | Debtor 1 | [ ] | $[ ] |
   | Year before last | Debtor 2 | [ ] | $[ ] |

Part 3: Payments to Creditors

6. Are debts primarily consumer debts? [No / Yes]
   - If No (not primarily consumer), list payments totaling $7,575 or more to any single creditor within 90 days (threshold subject to periodic adjustment).
   - If Yes (primarily consumer), list payments totaling $600 or more to any single creditor within 90 days.
   Do not include domestic support obligations or payments to a bankruptcy attorney for this case.
   | Creditor name/address | Account last 4 | Dates of payment | Total paid | Amount still owed | Debt type |
   | --- | --- | --- | ---: | ---: | --- |
   | [ ] | [####] | [ ] | $[ ] | $[ ] | [ ] |
7. Payments to insiders within 1 year? [No / Yes]
   | Insider name/relationship/address | Account last 4 | Dates of payment | Total paid | Amount still owed | Debt type |
   | --- | --- | --- | ---: | ---: | --- |
   | [ ] | [####] | [ ] | $[ ] | $[ ] | [ ] |
8. Payments or transfers that benefited an insider within 1 year? [No / Yes]
   | Insider who benefited | Person paid | Dates | Amount | Debt description |
   | --- | --- | --- | ---: | --- |
   | [ ] | [ ] | [ ] | $[ ] | [ ] |

Part 4: Legal Actions and Property Events

9. Lawsuits, court actions, or administrative proceedings within 1 year? [No / Yes]
   | Case title/number | Nature | Court/agency | Status |
   | --- | --- | --- | --- |
   | [ ] | [ ] | [ ] | [ ] |
10. Property repossessed, foreclosed, garnished, attached, seized, or levied within 1 year? [No / Yes]
    | Creditor | Property | Date | Value | Action (check) | Explanation |
    | --- | --- | --- | ---: | --- | --- |
    | [ ] | [ ] | [ ] | $[ ] | [Repossessed/Foreclosed/Garnished/Attached/Seized/Levied] | [ ] |
11. Setoffs within 90 days? [No / Yes]
    | Creditor | Account last 4 | Action taken | Date | Amount |
    | --- | --- | --- | --- | ---: |
    | [ ] | [####] | [ ] | [ ] | $[ ] |
12. Property in possession of assignee/receiver/custodian within 1 year? [No / Yes]
    | Custodian/assignee | Property | Date | Status |
    | --- | --- | --- | --- |
    | [ ] | [ ] | [ ] | [ ] |

Part 5: Gifts and Contributions

13. Gifts to individuals over $600 per person within 2 years? [No / Yes]
    | Recipient | Relationship | Description | Date | Value |
    | --- | --- | --- | --- | ---: |
    | [ ] | [ ] | [ ] | [ ] | $[ ] |
14. Gifts/contributions to charities over $600 within 2 years? [No / Yes]
    | Charity | Description | Date | Value |
    | --- | --- | --- | ---: |
    | [ ] | [ ] | [ ] | $[ ] |

Part 6: Losses

15. Losses from theft, fire, other disaster, or gambling within 1 year before filing or since filing? [No / Yes]
    | Property lost | Cause | Date | Value | Insurance coverage/claims |
    | --- | --- | --- | ---: | --- |
    | [ ] | [ ] | [ ] | $[ ] | [ ] |

Part 7: Certain Payments and Transfers

16. Payments/transfers to anyone you consulted about bankruptcy or preparing a petition within 1 year? [No / Yes]
    Include attorneys, bankruptcy petition preparers, or credit counseling agencies.
    | Person paid (name/address/email/website) | Payer if not you | Description/value of property transferred | Date | Amount |
    | --- | --- | --- | --- | ---: |
    | [ ] | [ ] | [ ] | [ ] | $[ ] |
17. Payments/transfers to anyone who promised to help with creditors or make payments to creditors within 1 year? [No / Yes]
    | Person paid | Address | Description/value of property transferred | Date | Amount |
    | --- | --- | --- | --- | ---: |
    | [ ] | [ ] | [ ] | [ ] | $[ ] |
18. Property transferred within 2 years (outside ordinary course)? [No / Yes]
    Include sales, trades, transfers, and transfers as security.
    | Transferee | Relationship | Property | Date | Value | What you received in exchange |
    | --- | --- | --- | --- | ---: | --- |
    | [ ] | [ ] | [ ] | [ ] | $[ ] | [ ] |
19. Property transferred to a self-settled trust within 10 years? [No / Yes]
    | Trust name | Property | Date | Value |
    | --- | --- | --- | ---: |
    | [ ] | [ ] | [ ] | $[ ] |

Part 8: Financial Accounts, Depositories, and Storage

20. Financial accounts or instruments closed/sold/moved/transferred within 1 year? [No / Yes]
    | Institution | Account type (check) | Account last 4 | Action | Date | Last balance |
    | --- | --- | --- | --- | --- | ---: |
    | [ ] | [Checking/Savings/CD/Brokerage/Other] | [####] | [ ] | [ ] | $[ ] |
21. Safe deposit box or other depository within 1 year? [No / Yes]
    | Institution | Address | Box number | Who had access | Contents | Still have it? |
    | --- | --- | --- | --- | --- | --- |
    | [ ] | [ ] | [ ] | [ ] | [ ] | [Yes/No] |
22. Storage unit or property stored outside home within 1 year? [No / Yes]
    | Facility | Address | Who had access | Contents | Still have it? |
    | --- | --- | --- | --- | --- |
    | [ ] | [ ] | [ ] | [ ] | [Yes/No] |

Part 9: Property Held for Others

23. Property you hold or control for someone else? [No / Yes]
    | Owner | Address | Property | Location | Value |
    | --- | --- | --- | --- | ---: |
    | [ ] | [ ] | [ ] | [ ] | $[ ] |

Part 10: Environmental Information

24. Notice of potential liability under environmental law? [No / Yes]
25. Notified a governmental unit of a release of hazardous material? [No / Yes]
26. Party in any environmental proceeding (including settlements/orders)? [No / Yes]
    If yes to any, provide: site name/address, governmental unit, environmental law (if known), date of notice, proceeding details.

Part 11: Business Information

27. Business connections within 4 years? [No / Yes]
    Check all that apply:
    - [ ] Sole proprietor/self-employed (full-time or part-time)
    - [ ] Member of LLC or LLP
    - [ ] Partner in a partnership
    - [ ] Officer/director/managing executive of a corporation
    - [ ] Owner of at least 5% of a corporation's voting or equity securities
    Provide details for each business:
    | Business name/address | Nature of business | EIN (last 4) | Role | Dates | Accountant/bookkeeper |
    | --- | --- | --- | --- | --- | --- |
    | [ ] | [ ] | [ ] | [ ] | [ ] | [ ] |
28. Financial statements about your business issued within 2 years? [No / Yes]
    | Recipient | Address | Date issued |
    | --- | --- | --- |
    | [ ] | [ ] | [ ] |

Part 12: Signature and Post-Signature Questions

I declare under penalty of perjury that the information provided is true and correct.

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

• Did you attach additional pages? [Yes/No]
• Did you pay or agree to pay someone who is not an attorney to help you fill out this form? [Yes/No]. If yes, attach Official Form 119.

Warning: 18 U.S.C. 152, 1341, 1519, and 3571 provide penalties for false statements, including fines up to $250,000 or imprisonment up to 20 years, or both.