Statement of Financial Affairs

IMPORTANT: THIS IS A PREPARATION GUIDE — NOT THE OFFICIAL COURT FORM

Federal bankruptcy filings require the use of Official Bankruptcy Form 107
(Statement of Financial Affairs for Individuals Filing for Bankruptcy) as mandated by Fed. R. Bankr. P. 9009. This template provides the
substantive legal content to help you prepare — but you must transfer your content to
the official form or your court's e-filing system before filing.
Official forms are available at https://www.uscourts.gov/forms/bankruptcy-forms.
Do not file this document directly with the court.

STATEMENT OF FINANCIAL AFFAIRS FOR INDIVIDUALS FILING FOR BANKRUPTCY

Table of Contents

1. Income
2. Payments to Creditors
3. Lawsuits and Collections
4. Gifts and Contributions
5. Losses
6. Payments and Transfers
7. Closed Accounts and Safe Deposit Boxes
8. Property Held for Another
9. Previous Addresses and Environmental Issues
10. Business and Financial Information

UNITED STATES BANKRUPTCY COURT

_____________ DISTRICT OF _____________

PART 1: INCOME

Question 1: Gross Income from Employment or Business

Provide gross income for the following periods:

Sources of income: [________________________________]

Question 2: Other Income

List any income other than from employment or operation of business for the same periods:

☐ None

PART 2: PAYMENTS TO CREDITORS

Question 3: Payments to Creditors Within 90 Days Before Filing

List all payments totaling more than $600 to any single creditor within 90 days before the filing date:

☐ None

Question 4: Payments to Insiders Within 1 Year Before Filing

List all payments to insiders (relatives, business partners, officers, directors) within 1 year before filing:

☐ None

PART 3: LAWSUITS AND COLLECTIONS

Question 5: Lawsuits, Executions, and Attachments

List all lawsuits, court actions, garnishments, or attachment of property within 1 year before filing:

☐ None

Question 6: Seizures, Repossessions, and Foreclosures

List all property seized, repossessed, or foreclosed within 1 year before filing:

☐ None

PART 4: GIFTS AND CONTRIBUTIONS

Question 7: Gifts or Charitable Contributions

List all gifts or contributions totaling more than $600 to any person or organization within 2 years before filing:

☐ None

PART 5: LOSSES

Question 8: Losses from Theft, Fire, or Disaster

List all losses from theft, fire, or other casualty within 1 year before filing or after filing:

☐ None

Question 9: Gambling Losses

List all losses from gambling within 1 year before filing or after filing:

☐ None

PART 6: PAYMENTS AND TRANSFERS

Question 10: Transfers of Property Within 2 Years

List all property sold, traded, given away, or otherwise transferred within 2 years before filing:

☐ None

Question 11: Self-Settled Trusts Within 10 Years

Have you created or transferred property to a self-settled trust within 10 years before filing?

☐ No
☐ Yes — Provide details: [________________________________]

PART 7: CLOSED ACCOUNTS AND SAFE DEPOSIT BOXES

Question 12: Closed Financial Accounts

List all financial accounts closed, moved, or transferred within 1 year before filing:

☐ None

Question 13: Safe Deposit Boxes

List all safe deposit boxes held within 1 year before filing:

☐ None

PART 8: PROPERTY HELD FOR ANOTHER

Question 14: Property Stored or Held for Others

List all property belonging to others in your possession or control:

☐ None

PART 9: PREVIOUS ADDRESSES AND ENVIRONMENTAL ISSUES

Question 15: Previous Addresses

List all addresses where you lived within 3 years before filing:

Question 16: Environmental Information

Has any property you own or have owned been the subject of environmental contamination or cleanup?

☐ No
☐ Yes — Details: [________________________________]

PART 10: BUSINESS AND FINANCIAL INFORMATION

Question 17: Business Ownership Within 4 Years

☐ None

Question 18: Financial Statements Issued Within 2 Years

List any financial statements provided to creditors or others within 2 years:

☐ None

DECLARATION UNDER PENALTY OF PERJURY

I declare under penalty of perjury that I have read the answers on this Statement of Financial Affairs and any attachments, and that they are true and correct.

☐ I understand that making a false statement, concealing property, or obtaining money or property by fraud in connection with a bankruptcy case can result in fines up to $250,000, or imprisonment for up to 20 years, or both (18 U.S.C. §§ 152, 1341, 1519, and 3571).

Debtor 1:

Signature: _________________________________ Date: [__/__/____]

Printed Name: _________________________________

Debtor 2 (if joint case):

Signature: _________________________________ Date: [__/__/____]

Printed Name: _________________________________

This template provides general guidance for completing the Statement of Financial Affairs per Official Form 107 and 11 U.S.C. § 521(a)(1)(B)(iii). Use the official form for actual filings. All answers are made under penalty of perjury.