Mean's Test Questionnaire

Please make certain this information is accurate!

Please complete this financial Information. Remember that we are basing all information on the form you filled out earlier, as supplemented by this information. WARNING: TO AVOID LOSING YOUR INFORMATION DO NOT TURN OFF YOUR COMPUTER OR LEAVE THIS SITE UNTIL THE FORM IS SUBMITTED (YOU WILL RECEIVE A CONFIRMATION WHEN IT IS SUBMITTED). PLEASE NOTE - WE DO NOT HAVE ACCESS TO ANY INFORMATION UNTIL THE FORM IS SUBMITTED.

INCOME & EXPENSE INFORMATION FOR AN INDIVIDUAL OR MARRIED COUPLE

THIS FORM IS JUST ABOUT INCOME AND EXPENSES. IT IS A FOLLOW UP TO YOUR INITIAL QUESTIONNAIRE - IF THAT INFORMATION WAS NOT CORRECT IT IS VERY IMPORTANT YOU FILL OUT A NEW QUESTIONNAIRE, NOT THIS FORM.

First Name*

Last Name*

Street Address*

City*

Your age*

Have you lived in Arizona for*

More than 2 years
Less than 2 years

Since you did not live Arizona for the last 2 years where did you live and for how long?*

Primary Phone*

Email*

Are you married?*

Yes
No

Information about your Spouse

Spouse's First Name*

Spouse's Last Name*

Spouses primary contact phone number*

Spouses e-mail address*

Spouse's age*

Year you were married.*

Do you and your spouse live together?*

Yes
No

Spouse's street Address*

City*

Do you have people who live with you or that you deduct on your taxes?*

Yes
No

Individual #1

Name

First Last

Age?

Relationship to you

Is this person living with you?

Yes
No

1 - Do you have additional people who live with you or that you deduct on your taxes?

Yes
No

Individual #2

Name

First Last

Age?

Relationship to you

Is this person living with you?

Yes
No

2 - Do you have additional people who live with you or that you deduct on your taxes?

Yes
No

Individual #3

Name

First Last

Age?

Relationship to you

Is this person living with you?

Yes
No

3 - Do you have additional people who live with you or that you deduct on your taxes?

Yes
No

Individual #4

Name

First Last

Age?

Relationship to you

Is this person living with you?

Yes
No

Are both you and your spouse filing this bankruptcy together?*

Yes
No

Do you owe any back child support or alimony?*

Yes
No

How much do you owe in back child support and/or alimony and to whom?

IMPORTANT: Do you normally receive a tax refund?*

Understand that any refunds you have not collected by the date a bankruptcy is filed will be sent to the bankruptcy trustee.

Yes
No

How much do you normally receive each year?

In the 12 months have you paid family or friends back on any loan?*

Yes
No

How much did you repay family or friends in the last year?

If you repaid any loans from family or friends we must discuss the ramifications.

Approximately how much do you owe which is business or non-personal debts. Make sure to include both secured and unsecured*

*Make sure to include debts for investment properties as secured business debts. *Also include any monies you charged on your personal credit cards but used for business purposes.

Is there a foreclosure or trustee’s sale pending?*

Yes
No

If so, what is the date and time of foreclosure?*

If there is a trustee's sale pending, please provide us a copy of trustee sale documents.

**It is your responsibility to confirm the trustee sale date and at all times to keep track of that date and any postponements; including the entire time your bankruptcy is pending. This office will not monitor the date of sale for you, but we be happy to answer your questions regarding the trustee sale process.

Are you in the middle of a divorce or separation?*

Yes
No

In the middle of a divorce or separation? Briefly explain your situation.

Financial Information & Monthly Budget

This form details how much you spend each month for basic living expenses. Be sure to include the MONTHLY (not yearly) amount for these expenses. In Arizona your utility bill is probably higher in the summer than the winter. Therefore take an average covering the last 12-month period. If you are married and your spouse does not reside with you please make a spreadsheet of their expenses and send them to our office. Make sure to include your name on the spreadsheet.

MONTHLY LIVING EXPENSES

First mortgage, mobile home payment or rent

Second mortgage (if applicable)

Third mortgage (if applicable)

Real estate taxes if it is are not included in house payment.

Home insurance if it is not included in house payment.

Homeowner's Association fees.

Other real estate payment (house, raw land or timeshare)

Average Monthly Utilities

Electricity and Gas - average monthly payment

Water - average monthly payment

Trash pickup (if not included in water)

Cable & Internet - average monthly payment

Telephone and Cell- average monthly payment

Monthly Basic Needs

Home Maintenance (for homeowners only)

Average out of pocket medical expenses (not paid by insurance).*

Make sure to include co-pays, pharmacy, eye-glasses and dental expenses. This is a monthly average based on what you have been spending. This amount does not include insurance premiums.

Do you have any children?*

Yes
No

Babysitter/Day Care Expenses

Taxes and other expenses

Taxes that are not deducted from your wages, Please provide amount and short explanation (such as "self-employed")

Do you owe back taxes?*

Yes
No

Back taxes*

Please list each year and amount owed for each year.

Life Insurance that is NOT deducted from a paycheck

Health Insurance that is NOT deducted from a paycheck

Disability Insurance that is NOT deducted from a paycheck

Other Insurance

Vehicles

Make sure to list all vehicles you own (whether paid in full or not); include any vehicles you own with someone else. List all payments, including leases.

Vehicle 1 Monthly Payment

Vehicle 2 Monthly Payment

Vehicle 3 Monthly Payment

Is vehicle 1 leased?

Yes
No

Is vehicle 2 leased?

Yes
No

Is vehicle 3 leased?

Yes
No

Other Monthly Expenses

Alimony or Child Support

Payments for someone outside your home

For instance, sending Grandma $200 per month to help pay her utility. We will need a history in order to show why this should be included as an expense.

Professional Dues NOT deducted in a paycheck

This may be an annual expenses, but you should divide it by 12 in order to determine the average monthly expense.

Union Dues NOT deducted in a paycheck

Student Loan Repayment(s)

Charitable Giving (if claimed on taxes)

(include church, Goodwill, etc.)

MEANS TEST - INCOME FROM ALL SOURCES RECEIVED IN THE LAST SIX MONTHS

Note on this income and means test

This test comes from the 2005 changes to the bankruptcy law. Neither you nor I like going through this analysis, but it is the law (somewhat like taking nasty tasting medicine).

Please read the directions below because this is the most complicated area we will be discussing, but it is extremely important. If you provide me with accurate information I can give you good legal advice. Please call if you have any questions.

Thanks in advance for your understanding and patience.

Are you a disabled vet?*

Yes
No

Are you currently or within the last 18 months on active duty or performing duties for homeland security?*

Yes
No

Is your Spouse a disabled vet?*

Yes
No

Is your Spouse currently or within the last 18 months on active duty or performing duties for homeland security?*

Yes
No

All income must be GROSS (before taxes and other deductions).

List income from each employer separately.

List all income in the month it was received, not the month it was due.

Include tips and bonuses in the month they were received.

If you receive a commission, list the amount earned in the month it was received.

Other income:

If income is earned as a sole proprietor - list all income in the month received.

If you receive a salary from your own company list that income in the month you receive it, not when the business received it.

Include retirement income.

Include disability income ; BUT MAKE SURE TO IDENTIFY IF IT IS SOCIAL SECURITY DISABILITY

Include Social Security, BUT MAKE SURE TO IDENTIFY IT AS SOCIAL SECURITY

Include all monies received from any source, including cashing in retirement accounts, sales of large items and tax refunds, etc. Identify the source.

RENTS: include money from rents (after deducting amount paid for mortgage/HOA/utilities, etc).

If someone is living with you - include their net income even if they do not give it to you. To calculate net income deduct their own expenses such as: taxes, insurance, expenses related to vehicles, medical, credit cards, student loans, other housing, business debts, etc.

Include all monies regularly received from gifts or loans from friends or relatives.

The income must be for a full month; therefore use the last full 6 months, do not include the current month.

It is better to list everything and then we can remove what does not apply to your situation.

The following chart is an example of how to fill out the means test form:

NOW IT IS YOUR TURN. DO YOUR BEST! WITHOUT ACCURATE INFORMATION IT IS VERY DIFFICULT FOR DIANE TO GIVE YOU GOOD ADVICE ABOUT BANKRUPTCY AND HOW IT WILL HELP YOU, OR EVEN IF IT WILL HELP YOU.

PLEASE CALL IF YOU HAVE ANY QUESTIONS at 602-246-7106:

Information about you - Please take your time and accurately fill out information about your income.

I cannot give you good advice without this information.

Your First Name*

I ask this in order to keep income from multiple sources organized.

Are you working or do you have income from any source (like retirement)? Is someone paying some of your bills? All of this is "income" and must be listed so we can do our best to give you good advice.*

Yes
No

If dad is paying your phone bill this is "income" and must be listed.

You said you DO NOT have any income, so please explain how you are eating, how you have a place to sleep or the ability to take care of yourself.*

Such as" I live with my parents and they pay for everything." If you are paying your own bills then go back to the question above and chose "yes" to the question "Do you have any income",

Employer name or other source of income*

Month 1*

Month 2*

Month 3*

Month 4*

Month 5*

Month 6*

Do you have a second source of income?*

Yes
No

Employer/Other*

Month 1*

Month 2*

Month 3*

Month 4*

Month 5*

Month 6*

Do you have a third source of income?*

Yes
No

Employer/Other*

Month 1*

Month 2*

Month 3*

Month 4*

Month 5*

Month 6*

Do you have a fourth source of income?*

Yes
No

Employer/Other*

Month 1*

Month 2*

Month 3*

Month 4*

Month 5*

Month 6*

Are you married or living with a significant other?*

Yes
No

Your spouse or significant other.

Spouse or significant other's name

Is your spouse or significant other receiving any money from any source?*

Yes
No

Employer/Other*

Month 1

Month 2

Month 3

Month 4

Month 5

Month 6

Employer/Other*

Month 1

Month 2

Month 3

Month 4

Month 5

Month 6

Employer/Other

Month 1

Month 2

Month 3

Month 4

Month 5

Month 6

NOW STOP!

Finish the following page ONLY if your average gross income (ANNUAL income before taxes and other deductions) exceeds the amount permitted for the number of people that live in your home. Normally that means the number of people you deduct on your tax returns, but there are always exceptions. The more accurate job you do here the more accurate legal advice I can give you.

For now include income for everyone who lives in your home. Prepare an explanation if your family has unusual income. Do not include anyone’s social security income as part of the following calculation.

Annual Gross Income (before any deductions) (these numbers change every 6 months, so may not be accurate): Family of 1 - $52,334 Family of 2 - $65,254 Family of 3 - $70,976 Family of 4 - $80,956 Family of 5 - $89,956 each additional person: $9,000

Does your average gross income (income before taxes and other deductions) exceed the amount permitted for a family of your size.*

Yes
No

Instructions for the following questions:

IMPORTANT: The following expenses are monthly, not annual and not per pay check.

These questions pertain NOT to what you were actually paid or received over the last six months. Instead, these are for expenses you will spend or should spend in the future. In other words, unlike income this is a forward looking review of your expenses.

(e.g.: what is the correct amount you should be deducting from your paycheck(s). Or, if you want but do not have life insurance, disability insurance, or health savings plan, etc. Make sure you talk to Diane about this.

Include all expenses, those deducted from your paychecks AND those that you pay directly in cash or by check.

How to calculate monthly expenses:

TAXES: If your income fluctuates then add all taxes for the 6 months above, including anticipated taxes on 1099 income then divide by 6.

Are you paid the same amount every week? If so, multiply the taxes from one paycheck by 52 and divide by 12 to determine your monthly taxes.

Are you paid the same amount every two weeks? If so, multiply the taxes from one paycheck by 26 and divide by 12 to determine your monthly taxes.

Monthly average taxes (federal, state, FICA, social security, Medicare and self-employment). If you include income for two people (spouse or signficiant other) then add taxes from all income and enter one number.*

Monthly MANDATORY payroll deductions (employer forces you to pay: e.g. union dues or forced retirement)

These are expenses that you are required to pay in order to work for this employer. For instance - if you work for the government they usually require you to contribute to a retirement account.

Monthly life insurance. This may be deducted from a paycheck or you pay the premium directly.

Monthly Court ordered payments (such as child support/alimony)

Monthly education expenses for employment or physically/mentally challenged child.

Monthly childcare costs.

Monthly health insurance deducted from paycheck or paid directly to the insurance company.

Make sure to include dental and all other insurance.

Monthly health care such as co-pays, pharmacy, eye-glasses, dental, etc (out-of-pocket, not paid by insurance)*

These expenses need to be averaged over 12 months, then divided by 12 in order to give an average for your "out of pocket" expense. Make sure to include all health care expenses (diabetes medication, eye exams, etc).

Monthly disability Insurance (deducted in paycheck or paid directly)

Monthly health savings account (flex accounts)

Monthly expenses for the care of elderly, chronically ill or disabled member of your household who cannot pay their own expenses:

Monthly protection against family violence

Monthly education expenses for children under 18 (such as uniforms and books)

Calculate these expenses over a 12 month period and divide by 12 in order to determine the average monthly expense.

Monthly charitable contributions - see your prior tax returns.

Monthly amount withheld to repay loans from retirement accounts.

Additional issues:

Do you owe any back taxes?*

Yes
No

Amount of back taxes owed.

Year(s) tax debt due:

Are you behind on payments to secured creditors (house or car)?

Yes
No

Name of Lender. Indicate if home or vehicle.

Amount owed to bring the loan current:

Are you behind on any other payments to secured creditors (house or car)?

Yes
No

Name of Lender. Indicate if home or vehicle.

Amount owed to bring the loan current:

Lender's name and state type of property: home or vehicle

Amount owed to bring the loan current:

Check the box below and submit your form.*

I Confirm I have read and understand the above legal notices

If the form does not submit when you press the button then you need to scroll through the form looking for red paragraphs that need answers. If it is successfully submitted you will receive a notification. Therefore, if you do not receive that email it was not successfully submitted and you need to go back and check what was not completed in the third section.

Comments

This field is for validation purposes and should be left unchanged.

Mean’s Test Questionnaire

Please make certain this information is accurate!

INCOME & EXPENSE INFORMATION FOR AN INDIVIDUAL OR MARRIED COUPLE

Information about your Spouse

Individual #1

Individual #2

Individual #3

Individual #4

Financial Information & Monthly Budget

MONTHLY LIVING EXPENSES

Average Monthly Utilities

Monthly Basic Needs

Taxes and other expenses

Vehicles

Other Monthly Expenses

MEANS TEST - INCOME FROM ALL SOURCES RECEIVED IN THE LAST SIX MONTHS

Note on this income and means test

All income must be GROSS (before taxes and other deductions).

Other income:

The following chart is an example of how to fill out the means test form:

NOW IT IS YOUR TURN. DO YOUR BEST! WITHOUT ACCURATE INFORMATION IT IS VERY DIFFICULT FOR DIANE TO GIVE YOU GOOD ADVICE ABOUT BANKRUPTCY AND HOW IT WILL HELP YOU, OR EVEN IF IT WILL HELP YOU.

Information about you - Please take your time and accurately fill out information about your income.

Your spouse or significant other.

NOW STOP!

Instructions for the following questions:

How to calculate monthly expenses:

Additional issues:

Helpful Quick Links

Bankruptcy Questions

Resources

Mean’s Test Questionnaire

Please make certain this information is accurate!

INCOME & EXPENSE INFORMATION FOR AN INDIVIDUAL OR MARRIED COUPLE

Information about your Spouse

Individual #1

Individual #2

Individual #3

Individual #4

Financial Information & Monthly Budget

MONTHLY LIVING EXPENSES

Average Monthly Utilities

Monthly Basic Needs

Taxes and other expenses

Vehicles

Other Monthly Expenses

MEANS TEST - INCOME FROM ALL SOURCES RECEIVED IN THE LAST SIX MONTHS

Note on this income and means test

All income must be GROSS (before taxes and other deductions).

Other income:

The following chart is an example of how to fill out the means test form:

***NOW IT IS YOUR TURN. DO YOUR BEST!*** WITHOUT ACCURATE INFORMATION IT IS VERY DIFFICULT FOR DIANE TO GIVE YOU GOOD ADVICE ABOUT BANKRUPTCY AND HOW IT WILL HELP YOU, OR EVEN IF IT WILL HELP YOU.

Information about you - Please take your time and accurately fill out information about your income.

Your spouse or significant other.

NOW STOP!

Instructions for the following questions:

How to calculate monthly expenses:

Additional issues:

Helpful Quick Links

Bankruptcy Questions

Resources

NOW IT IS YOUR TURN. DO YOUR BEST! WITHOUT ACCURATE INFORMATION IT IS VERY DIFFICULT FOR DIANE TO GIVE YOU GOOD ADVICE ABOUT BANKRUPTCY AND HOW IT WILL HELP YOU, OR EVEN IF IT WILL HELP YOU.