Law Offices of Travis A. Gagnier, Inc. P.S.

Legal Solutions to Financial Challenges

Bankruptcy, Chapter 13, Chapter 7, Reorganization

Serving clients throughout western Washington
Offices in Seattle, Marysville, Federal Way, Edmonds, Southcenter & Tacoma.

Seattle: 206-622-0123
Tacoma: 253-927-7117
Edmonds: 425-242-4333
Marysville: 360-200-4400
Federal Way: 253-941-0234
Southcenter: 253-852-8114

TOLL FREE: 1-888-830-0350

Bankruptcy Questionnaire

Fill out this form as best you can and then press SUBMIT. It will be emailed to me directly. I will then review it and contact you.

Thank you,
Travis A. Gagnier

Please don't let the length of the Questionnaire bother you, most of the questions are simply Yes or No questions.

Name

First

Last

What is your middle name?

Date of birth

Email address

Best phone number to contact you at

Home Address Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Mailing address if different from home address

What is your current marital status? Single, Married, Married but living separately, Defacto Relationship

Spouse's Name

First

Last

Have you been involved in a Bankruptcy in the last 8 years? Yes No

Have you lived in Western Washington the preceding 3 years? Yes No

Are you currently self employed--have your own business, real estate agent or work on 1099? Yes No

Is there any property that is due you from someone who has died? Are you a beneficiary of a living trust, expect to receive proceeds from a life insurance policy, and/or have inherited something from an existing estate?

Does anyone owe you money or property for any reason? Please describe:

Do you have any other claims like a personal injury case (like from a car accident), class action claim or other lawsuit you could bring? Answer "yes" even if you have not filed suit or filed a claim, but you could do so. Yes No Not Sure

Do you owe money on a home, land or any real estate? Yes No

Do you owe money on a car, boat, truck, motorcycle? Anything with a title? Yes No

Is one or more of your vehicles in danger of being repo'd or have one recently been repo'd? Yes No Not Sure

Do you owe any money to the IRS or any other taxing authority? Yes No Not Sure

Within the last 12 months have you been involved in any lawsuit, court action or administrative proceeding? Yes No Not Sure

Within the last 12 months has any of your property been repossessed, foreclosed upon, garnished, attached, seized or levied upon? Yes No Not Sure

Are you being garnished currently? Yes No

Do you have any judgments against you? Yes No Not Sure

Does anyone claim you defrauded them? Yes No Not Sure

Is your home mortgage behind? Yes No Does Not Apply

If you home mortgage or property taxes are behind, have you received a Notice of Default, Notice of Trustee Sale or lawsuit to foreclose? Yes No Does Not Apply

Do you owe any current or back due child support, alimony, maintenance or property settlement? Yes No Not Sure

Has anyone cosigned a debt for you (like a car loan)? Yes No Not Sure

Do you owe money to any relative? Yes No Not Sure

In the last 12 months, have you repaid any money to a relative, transferred or sold any property to a relative? Yes No Not Sure

Do you have copies of the last 2 federal income tax returns you have filed? Yes No Not Sure

If you have not filed all required federal income tax returns, indicate the missing years below:

Have you filed all required federal income tax returns? Yes No Not Sure

Have any tax liens been filed against you? Yes No Not Sure

In the last 90 days have you gotten cash advances on your credit cards of more than $750 or take out any new payday loans? Yes No Not Sure

Within the last 24 months have you made a gift of money or property to any person or institution of more than $600? This includes charitable contributions like tithing. Yes No Not Sure

Do you owe money to a financial institution in which you have funds(checking, savings, cd, etc.)? Yes No Not Sure

Is your primary checking/savings account(s) with a credit union? Yes No Not Sure

If your primary checking/savings is with a credit union, do you owe money to that same credit union? Yes No Does Not Apply

Within the last 12 months did you lose anything because of fire, theft, or other disaster? Yes No Not Sure

Within the last 12 months, have you spent any money gambling? (showing on bank statements or tax returns) Yes No Not Sure

Do you have any money , property, furniture, etc.that belongs to another person or that you are holding for the benefit of someone else? Yes No Not Sure

Did you purchase or refinance a car, truck or other vehicle in the past year? Yes No

Do you have a vehicle loan with a credit union AND other debt with the same credit union (like a credit card or credit line)? Yes No Not Sure

Is any of your property in possession of a pawnbroker, storage company or repairman? Yes No

Within the last 12 months did you transfer any property or money to anyone who promised to help you deal with creditors? Yes No Not Sure

Within the last two (2) years did you sell, trade or otherwise transfer any property to anyone? For example, did you sell or trade in a vehicle, transfer title to a vehicle or other property to a friend or relative? Yes No Not Sure

Have you sold or transferred any interest in real estate, like a house, in the last two (2) years? This includes sales or transfers incident to a divorce. Yes No Not Sure

Do you now have or have you had in the last one (1) year a safety deposit box? Yes No Not Sure

Do you now have or have you had in the last one (1) year a storage unit? Yes No Not Sure

Do you hold or control any property belonging to anyone else? Yes No Not Sure

Within the last 4 years have you owned a business as a sole proprietorship, LLC, partnership, corporation or have you been an officer, managing executive of a corporation? Yes No Not Sure

Have you been self-employed in the last three (3) years? Yes No

Have you ever been issued an Employer Identification Number (EIN)? Yes No Not Sure

Do you have an interest in a timeshare or vacation plan? Yes No Not Sure

If you are renting has your landlord obtained an eviction judgment against you? Yes No Does Not Apply

Have you been divorced in the last six (6) years? Yes No Not Sure

Please list the age and gender of everyone residing in your household (such as, daughter 12, spouse 47, step-son 6, mother 71, granddaughter 2):

Please list the gender and ages of all children whom you support, whether wholly or in part, that do NOT reside in your household (such as, son 4, daughter 16):

Do any of the adults that reside in your household besides your spouse contribute to the household budget? If "yes", please describe (such as "mom lives with us and contributes $500/mo" or "my adult son lives at home and pays $400/mo rent").

Is you or spouse's driver's license suspended? Yes No Not Sure

Is your driver's license suspended due to uninsured vehicle accident(s)? Yes No Does Not Apply

Is your driver's license suspended due to unpaid tickets and/or fines? Yes No Does Not Apply

If you driver's license is suspended due to unpaid tickets and/or fines and/or uninsured accidents, are all the unpaid tickets, fines and accidents from within the state of Washington? Yes No Not Sure