RICHARD PIERCE, Attorney

Butler, Landrum and Pierce
720 Kipling St., Suite 201
Lakewood, Colorado 80215-5866
303/ 232-3888
Fax 303/ 232-3892
piercerh@worldnet.att.net

Provide copies of the following:

1) 	Paystubs received in previous 60 days 

2) 	Most recent filed Federal and State tax return 

Bankruptcy laws require completion of a Pre-Bankruptcy Counseling briefing before you file for bankruptcy. You may take this course on-line, by phone, or in-person.

1) 	www.PersonalFinanceEducation.com, 1-866-729-0049 

2) 	www.CricketDebt.com , 1-866-719-0400 

3) 	website listing approved course providers: 

http://www.usdoj.gov/ust/eo/bapcpa/ccde/CC_Files/CC_Approved_Agencies_HTML/cc_colorado/cc_colorado.htm

Complete All Questions. If you and your spouse are not living together, and there is no possibility that your spouse will file bankruptcy along with you, you don't have to answer the questions about your spouse.

1. | Name and Residence Information: Joint Filing( | )  Single Filing ( | )
A. | Your full name: | | Your Social Security Number:
B. | Spouse’s full name: | | Spouse’s Social Security Number:

C. 	List any other names used by you or your spouse (including maiden name), or other ways you have signed your names to papers and checks during the last eight years: 

D. 	Current Address/PO Box if applicable: 

(Street)

(City)	(County)	(Zip Code)

E. 	Telephone Number(s): Email Address: 

F. 	List all addresses you have had in the last three years, the dates when you lived there, and the name you used while living there. If you and your spouse are filing bankruptcy together, list addresses for each for the last three years (include street, town, and zip code). 

Addresses	Date Moved In	Date Moved Out	Name Used

1

2. Prior Bankruptcy: Have you or your spouse ever been involved before in a bankruptcy (chapter 7, 11, 12, or 13)? YES___ NO___. If YES, bring all papers from the case(s) to our office.

| | | | If Dismissed, List
What | | Did You Get | If Yes, List Date | Date and Reason
Chapter? | Date Case Filed/State Filed | a Discharge? | of Discharge | Why Dismissed

3. 	Other Bankruptcies: Have there been any other bankruptcies filed by someone other than you or your spouse to stop a foreclosure on your home? YES _____ NO _____. If YES, give details: 

4. 	Occupation and Income: 

A. 	Usual type of work: 

B. 	Name and address of current employer: 

C. 	Spouse’s usual type of work: 

D. 	Name and address of spouse’s current employer: 

E.    How long have you been at your current job?	Your spouse?

F. 	List all income received in the last six months by you and your spouse (do not list your spouse’s income if you are not filing bankruptcy together and you are legally separated): 

	(Bring a copy with you to our office of all pay stubs or other records from your employer of all pay received within the past sixty days.) 

Source (Names of employer or specify

Income Received

(Give gross income)

social security, unemployment, child support, self-employment, investments, etc.)

By Whom

(Self or Spouse)

1 month ago:

2 months ago:

3 months ago:

2

4 months ago:

5 months ago:

6 months ago:

G. 	Have you or your spouse been in business by yourself or with others during the last six years? 

	YES ____ NO ____. If yes, give the dates, name of the business, its address, and the names of others in business with you or your spouse. 

H. 	Are there any debts from your former business?  YES ___ NO ___.  If YES, here: 

I. 	(1) If you employed anyone (such as regular employees, cleaning people, gardeners, babysitters), do you still owe them wages? YES ___ NO ___. If YES, give name and address of employee, dates worked, amount owed, and work done. 

(2) 	Has anyone given you money to purchase property or services that you were unable to provide? YES ___ NO ___. If YES, give details: 

J. 	Have you ever been on welfare within the past two years? YES ___ NO ___. Has anyone in your immediate family? YES ___ NO ___. If YES to either question, specify the persons, dates, amounts received, and places (if state welfare, name the state; if local welfare, name the city or county). 

K. 	Have you ever received or been told you have received more money from the government than you were supposed to (such as social security, welfare, unemployment compensation, food stamps, etc.)? 
	YES _____  NO _____. If YES, give details: 

L. 	Do you have any vacation time that is due you from your employer?  YES _____ NO _____.  If YES, how much is