Statement of Financial Affairs (United States)
This is a supplemental form to a Bankruptcy and is a statement of financial affairs. The form provided here is simply a sample of what the actual Form 7 looks like.
Form 7
(9/00)
FORM 7. STATEMENT OF FINANCIAL AFFAIRS
UNITED STATES BANKRUPTCY COURT
_____________________ DISTRICT OF ______________________
In re: ______________________________________ (Debtor Name),
Case No. ___________________________________ (if known)
STATEMENT OF FINANCIAL AFFAIRS
This statement is to be completed by every debtor. Spouses filing a joint petition may file a single statement on which the information for both spouses is combined. If the case is filed under chapter 12 or chapter 13, a married debtor must furnish information for both spouses whether or not a joint petition is filed, unless the spouses are separated and a joint petition is not filed. An individual debtor engaged in business as a sole proprietor, partner, family farmer, or self-employed professional, should provide the information requested on this statement concerning all such activities as well as the individual's personal affairs.
Questions 1-18 are to be completed by all debtors. Debtors that are or have been in business, as defined below, also must complete Questions 19-25. If the answer to an applicable question is "None," mark the box labeled "None." If additional space is needed for the answer to any question, use and attach a separate sheet properly identified with the case name, case number (if known), and the number of the question.
DEFINITIONS
"In business." A debtor is "in business" for the purpose of this form if the debtor is a corporation or partnership. An individual debtor is "in business" for the purpose of this form if the debtor is or has been, within the six years immediately preceding the filing of this bankruptcy case, any of the following: an officer, director, managing executive, or owner of 5 percent or more of the voting or equity securities of a corporation; a partner, other than a limited partner, of a partnership; a sole proprietor or self-employed.
"Insider." The term "insider" includes but is not limited to: relatives of the debtor; general partners of the debtor and their relatives; corporations of which the debtor is an officer, director, or person in control; officers, directors, and any owner of 5 percent or more of the voting or equity securities of a corporate debtor and their relatives; affiliates of the debtor and insiders of such affiliates; any managing agent of the debtor. 11 U.S.C. § 101.
1. Income from employment or operation of business
____ None
State the gross amount of income the debtor has received from employment, trade, or profession, or from operation of the debtor's business from the beginning of this calendar year to the date this case was commenced. State also the gross amounts received during the two years immediately preceding this calendar year. (A debtor that maintains, or has maintained, financial records on the basis of a fiscal rather than a calendar year may report fiscal year income. Identify the beginning and ending dates of the debtor's fiscal year.) If a joint petition is filed, state income for each spouse separately. (Married debtors filing under chapter 12 or chapter 13 must state income of both spouses whether or not a joint petition is filed, unless the spouses are separated and a joint petition is not filed.)
AMOUNT ____________________________
SOURCE (if more than one) ____________________________
2. Income other than from employment or operation of business
____ None
State the amount of income received by the debtor other than from employment, trade, profession, or operation of the debtor's business during the two years immediately preceding the commencement of this case. Give particulars. If a joint petition is filed, state income for each spouse separately. (Married debtors filing under chapter 12 or chapter 13 must state income for each spouse whether or not a joint petition is filed, unless the spouses are separated and a joint petition is not filed.)
AMOUNT ____________________________
SOURCE ____________________________
3. Payments to creditors
____ None
a. 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. (Married debtors filing under chapter 12 or chapter 13 must include payments by either or both spouses whether or not a joint petition is filed, unless the spouses are separated and a joint petition is not filed.)
NAME AND ADDRESS OF CREDITOR ____________________________
DATES OF PAYMENTS ____________________________
AMOUNT PAID ____________________________
AMOUNT STILL OWING ____________________________
____ None
b. 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. (Married debtors filing under chapter 12 or chapter 13 must include payments by either or both spouses whether or not a joint petition is filed, unless the spouses are separated and a joint petition is not filed.)
NAME AND ADDRESS OF CREDITOR AND RELATIONSHIP TO DEBTOR
____________________________
____________________________
____________________________
DATE OF PAYMENT ____________________________
AMOUNT PAID ____________________________
AMOUNT STILL OWING ____________________________
4. Suits and administrative proceedings, executions, garnishments and attachments
____ None
a. List all suits and administrative proceedings to which the debtor is or was a party within one year immediately preceding the filing of this bankruptcy case. (Married debtors filing under chapter 12 or chapter 13 must include information concerning either or both spouses whether or not a joint petition is filed, unless the spouses are separated and a joint petition is not filed.)
CAPTION OF SUIT AND CASE NUMBER ____________________________
NATURE OF PROCEEDING ____________________________
COURT OR AGENCY AND LOCATION ____________________________
STATUS OR DISPOSITION ____________________________
___ None
b. Describe all property that has been attached, garnished or seized under any legal or equitable process within one year immediately preceding the commencement of this case. (Married debtors filing under chapter 12 or chapter 13 must include information concerning property of either or both spouses whether or not a joint petition is filed, unless the spouses are separated and a joint petition is not filed.)
NAME AND ADDRESS OF PERSON FOR WHOSE BENEFIT PROPERTY WAS SEIZED ____________________________
DATE OF SEIZURE ____________________________
DESCRIPTION AND VALUE OF PROPERTY ____________________________
5. Repossessions, foreclosures and returns
____ None
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. (Married debtors filing under chapter 12 or chapter 13 must include information concerning property of either or both spouses whether or not a joint petition is filed, unless the spouses are separated and a joint petition is not filed.)
NAME AND ADDRESS OF CREDITOR OR SELLER ____________________________
DATE OF REPOSSESSION, FORECLOSURE SALE, TRANSFER OR RETURN ____________________________
DESCRIPTION AND VALUE OF PROPERTY ____________________________
6. Assignments and receiverships
____ None
a. Describe any assignment of property for the benefit of creditors made within 120 days immediately preceding the commencement of this case. (Married debtors filing under chapter 12 or chapter 13 must include any assignment by either or both spouses whether or not a joint petition is filed, unless the spouses are separated and a joint petition is not filed.)
NAME AND ADDRESS OF ASSIGNEE ____________________________
____________________________
____________________________
DATE OF ASSIGNMENT ____________________________
TERMS OF ASSIGNMENT OR SETTLEMENT ____________________________
____ None
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. (Married debtors filing under chapter 12 or chapter 13 must include information concerning property of either or both spouses whether or not a joint petition is filed, unless the spouses are separated and a joint petition is not filed.)
NAME AND ADDRESS OF CUSTODIAN ____________________________
NAME AND LOCATION OF COURT CASE TITLE & NUMBER ____________________________
DESCRIPTION AND VALUE OF PROPERTY ____________________________
DATE OF ORDER ____________________________
7. Gifts
____ None
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. (Married debtors filing under chapter 12 or chapter 13 must include gifts or contributions by either or both spouses whether or not a joint petition is filed, unless the spouses are separated and a joint petition is not filed.)
NAME AND ADDRESS OF PERSON OR ORGANIZATION
____________________________
____________________________
____________________________
RELATIONSHIP TO DEBTOR, IF ANY ____________________________
DATE OF GIFT ____________________________
DESCRIPTION AND VALUE OF GIFT ____________________________
8. Losses
____ None
List all losses from fire, theft, other casualty or gambling within one year immediately preceding the commencement of this case or since the commencement of this case. (Married debtors filing under chapter 12 or chapter 13 must include losses by either or both spouses whether or not a joint petition is filed, unless the spouses are separated and a joint petition is not filed.)
DESCRIPTION AND VALUE OF PROPERTY ____________________________
DESCRIPTION OF CIRCUMSTANCES AND, IF LOSS WAS COVERED IN WHOLE OR IN PART BY INSURANCE, GIVE PARTICULARS ____________________________
DATE OF LOSS ____________________________
9. Payments related to debt counseling or bankruptcy
____ None
List all payments made or property transferred by or on behalf of the debtor to any persons, including attorneys, for consultation concerning debt consolidation, relief under the bankruptcy law or preparation of a petition in bankruptcy within one year immediately preceding the commencement of this case.
NAME AND ADDRESS OF PAYEE ____________________________
____________________________
____________________________
DATE OF PAYMENT, NAME OF PAYOR IF OTHER THAN DEBTOR ____________________________
AMOUNT OF MONEY OR DESCRIPTION AND VALUE OF PROPERTY ____________________________
10. Other transfers
____None
List all other property, other than property transferred in the ordinary course of the business or financial affairs of the debtor, transferred either absolutely or as security within one year immediately preceding the commencement of this case. (Married debtors filing under chapter 12 or chapter 13 must include transfers by either or both spouses whether or not a joint petition is filed, unless the spouses are separated and a joint petition is not filed.)
NAME AND ADDRESS OF TRANSFEREE, RELATIONSHIP TO DEBTOR
____________________________
____________________________
____________________________
DATE ____________________________
DESCRIBE PROPERTY TRANSFERRED AND VALUE RECEIVED ____________________________
11. Closed financial accounts
____ None
List all financial accounts and instruments held in the name of the debtor or for the benefit of the debtor which were closed, sold, or otherwise transferred within one year immediately preceding the commencement of this case. Include checking, savings, or other financial accounts, certificates of deposit, or other instruments; shares and share accounts held in banks, credit unions, pension funds, cooperatives, associations, brokerage houses and other financial institutions. (Married debtors filing under chapter 12 or chapter 13 must include information concerning accounts or instruments held by or for either or both spouses whether or not a joint petition is filed, unless the spouses are separated and a joint petition is not filed.)
NAME AND ADDRESS OF INSTITUTION ____________________________
TYPE AND NUMBER OF ACCOUNT AND AMOUNT OF FINAL BALANCE ____________________________
AMOUNT AND DATE OF SALE OR CLOSING ____________________________
12. Safe deposit boxes
____ None
List each safe deposit or other box or depository in which the debtor has or had securities, cash, or other valuables within one year immediately preceding the commencement of this case. (Married debtors filing under chapter 12 or chapter 13 must include boxes or depositories of either or both spouses whether or not a joint petition is filed, unless the spouses are separated and a joint petition is not filed.)
NAME AND ADDRESS OF BANK OR OTHER DEPOSITORY
____________________________
____________________________
____________________________
NAMES AND ADDRESSES OF THOSE WITH ACCESS TO BOX OR DEPOSITORY
____________________________
____________________________
____________________________
DESCRIPTION OF CONTENTS ____________________________
DATE OF TRANSFER OR SURRENDER, IF ANY ____________________________
13. Setoffs
None List all setoffs made by any creditor, including a bank, against a debt or deposit of the debtor within 90 days preceding the commencement of this case. (Married debtors filing under chapter 12 or chapter 13 must include information concerning either or both spouses whether or not a joint petition is filed, unless the spouses are separated and a joint petition is not filed.)
NAME AND ADDRESS OF CREDITOR ____________________________
____________________________
____________________________
DATE OF SETOFF ____________________________
AMOUNT OF SETOFF ____________________________
14. Property held for another person
____ None
List all property owned by another person that the debtor holds or controls.
NAME AND ADDRESS OF OWNER ____________________________
____________________________
____________________________
DESCRIPTION AND VALUE OF PROPERTY ____________________________
LOCATION OF PROPERTY ____________________________
15. Prior address of debtor
____ None
If the debtor has moved within the two years immediately preceding the commencement of this case, list all premises which the debtor occupied during that period and vacated prior to the commencement of this case. If a joint petition is filed, report also any separate address of either spouse.
ADDRESS ____________________________
NAME USED ____________________________
DATES OF OCCUPANCY ____________________________
16. Spouses and Former Spouses
____ None
If the debtor resides 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 six-year period immediately preceding the commencement of the case, identify the name of the debtor's spouse and of any former spouse who resides or resided with the debtor in the community property state.
NAME ____________________________
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
____ None
a. List the name and address of every site for which the debtor has 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:
SITE NAME AND ADDRESS ____________________________
NAME AND ADDRESS OF GOVERNMENTAL UNIT
____________________________
____________________________
____________________________
DATE OF NOTICE ____________________________
ENVIRONMENTAL LAW ____________________________
____ None
b. List the name and address of every site for which the debtor 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.
SITE NAME AND ADDRESS ____________________________
NAME AND ADDRESS OF GOVERNMENTAL UNIT
____________________________
____________________________
____________________________
DATE OF NOTICE ____________________________
ENVIRONMENTAL LAW ____________________________
____ None
c. List all judicial or administrative proceedings, including settlements or orders, under any Environmental Law with respect to which the debtor is or was a party. Indicate the name and address of the governmental unit that is or was a party to the proceeding, and the docket number.
NAME AND ADDRESS OF GOVERNMENTAL UNIT
____________________________
____________________________
____________________________
DOCKET NUMBER ____________________________
STATUS OR DISPOSITION ____________________________
18 . Nature, location and name of business
____ None
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.
NAME ____________________________
TAXPAYER I.D. NUMBER ____________________________
ADDRESS ____________________________
NATURE OF BUSINESS ____________________________
BEGINNING AND ENDING DATES ____________________________
____ None 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.
NAME ____________________________
ADDRESS ____________________________
____________________________
____________________________
The following questions are to be completed by every debtor that is a corporation or partnership and by any individual debtor who is or has been, within the six years immediately preceding the commencement of this case, any of the following: an officer, director, managing executive, or owner of more than 5 percent of the voting or equity securities of a corporation; a partner, other than a limited partner, of a partnership; a sole proprietor or otherwise self-employed.
(An individual or joint debtor should complete this portion of the statement only if the debtor is or has been in business, as defined above, within the six years immediately preceding the commencement of this case. A debtor who has not been in business within those six years should go directly to the signature page.)
19. Books, records and financial statements
____ None
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 of the debtor.
NAME AND ADDRESS ____________________________
DATES SERVICES RENDERED ____________________________
____ None
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.
NAME ADDRESS ____________________________
DATES SERVICES RENDERED ____________________________
____ None
c. List all firms or individuals who at the time of the commencement of this case were in possession of the books of account and records of the debtor. If any of the books of account and records are not available, explain.
NAME ____________________________
ADDRESS ____________________________
____ None
d. List all financial institutions, creditors and other parties, including mercantile and trade agencies, to whom a financial statement was issued within the two years immediately preceding the commencement of this case by the debtor.
NAME AND ADDRESS ____________________________
____________________________
____________________________
DATE ISSUED ____________________________
20. Inventories
____ None
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.
DATE OF INVENTORY ____________________________
INVENTORY SUPERVISOR ____________________________
DOLLAR AMOUNT OF INVENTORY (Specify cost, market or other basis) ____________________________
____ None
b. List the name and address of the person having possession of the records of each of the two inventories reported in a., above.
DATE OF INVENTORY ____________________________
NAME AND ADDRESSES OF CUSTODIAN OF INVENTORY RECORDS
____________________________
____________________________
____________________________
21. Current Partners, Officers, Directors and Shareholders
____ None
a. If the debtor is a partnership, list the nature and percentage of partnership interest of each member of the partnership.
NAME AND ADDRESS ____________________________
NATURE OF INTEREST ____________________________
PERCENTAGE OF INTEREST ____________________________
____ None
b. If the debtor is a corporation, list all officers and directors of the corporation, and each stockholder who directly or indirectly owns, controls, or holds 5 percent or more of the voting or equity securities of the corporation.
NAME AND ADDRESS ____________________________
____________________________
____________________________
TITLE ____________________________
NATURE AND PERCENTAGE OF STOCK OWNERSHIP ____________________________
22. Former partners, officers, directors and shareholders
____ None
a. If the debtor is a partnership, list each member who withdrew from the partnership within one year immediately preceding the commencement of this case.
NAME ____________________________
ADDRESS ____________________________
DATE OF WITHDRAWAL ____________________________
None b. If the debtor is a corporation, list all officers, or directors whose relationship with the corporation terminated within one year immediately preceding the commencement of this case.
NAME AND ADDRESS ____________________________
____________________________
____________________________
TITLE ____________________________
DATE OF TERMINATION ____________________________
23. Withdrawals from a partnership or distributions by a corporation None If the debtor 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.
NAME & ADDRESS OF RECIPIENT, RELATIONSHIP TO DEBTOR ____________________________
DATE AND PURPOSE OF WITHDRAWAL ____________________________
AMOUNT OF MONEY OR DESCRIPTION AND VALUE OF PROPERTY ____________________________
24. Tax Consolidation Group.
None 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.
NAME OF PARENT CORPORATION ____________________________
TAXPAYER IDENTIFICATION NUMBER ____________________________
25. Pension Funds.
None 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.
NAME OF PENSION FUND ____________________________
TAXPAYER IDENTIFICATION NUMBER ____________________________