Statement of Financial Affairs Template (Official Form 107)

United States Bankruptcy Court
District of [District]

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

Debtor(s) must answer the following questions fully and truthfully. Provide attachments if additional space needed.

Part 1: Income

1. Gross income received from employment or business during current and previous two calendar years. Include employer name, address, amount, and date.
2. Non-employment income (rental, interest, retirement, government benefits).

Part 2: Payments to Creditors

3. Payments within 90 days before filing totaling more than $600 to any creditor (list names, dates, amounts).
4. Payments within 1 year before filing to insiders (relatives, partners, corporations in which debtor has interest).

Part 3: Transfers

5. Repossessions, foreclosures, setoffs within 90 days before filing.
6. Gifts or charitable contributions exceeding $[amount] within 2 years.
7. Transfers of property outside ordinary course within 2 years (include sales, trades, title transfers).
8. Transfers to self-settled trusts within 10 years.

Part 4: Financial Accounts and Safe Deposit Boxes

9. Closed financial accounts within 1 year (bank, credit union, securities).
10. Safe deposit boxes or storage units accessed within 1 year.

Part 5: Business Interests and Employment

11. Current/former businesses operated within 4 years (name, EIN, nature, dates).
12. Officers, directors, partners within 4 years.

Part 6: Lawsuits, Administrative Actions, and Garnishments

13. Pending or recent lawsuits to which debtor is party (case name, court, status).
14. Property garnished, attached, seized within 1 year.

Part 7: Executory Contracts and Leases

15. List leases or executory contracts (real property, vehicles, equipment) and parties involved.

Part 8: Financial Statements

16. Financial statements furnished to creditors within 2 years (date, recipient).

Part 9: Personal Property and Losses

17. Losses from fire, theft, gambling within 1 year.
18. Payments for debt counseling or bankruptcy assistance.
19. Prior bankruptcy cases filed within 8 years.

Part 10: General Information

20. Address history for past 3 years.
21. Spouses or former spouses.
22. Any property held or controlled for another person.

Declaration

I declare under penalty of perjury that the answers provided are true and correct.

Debtor 1 Signature: __________________________ Date: __________

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

Prepared by (if not debtor): [Name/Title]
Address: [Address]

Ensure compliance with Official Form 107 instructions; attach continuation sheets as required.

Local Rules Checklist

• Confirm local bankruptcy rules, judge procedures, and any required local forms.
• Verify notice and service requirements, including creditor matrix format.
• Check deadlines in the scheduling order and use the correct CM/ECF event.