Creditors

List all organizations and persons to whom you owe money, even if you are unsure of the amount. List creditors that have only possible claims, such as: debt you have co-signed; VA and FHA guarantees on you home or a home you have sold; debt on homes, cars, etc. which have been sold; ex-spouses; persons injured in automobile or other accidents. You will still owe creditors that you do not list. We list only creditors that you list below--debt just mentioned to your attorney or our staff will not be listed. Some Help with the Questions Creditor name and address. We will use the addresses which you give us. If the address is wrong you may still owe the debt. Account numbers are not required, but are helpful, especially in Chapter 13. Date incurred is the date that the loan was made. For charge cards, use the date of the charge after the last zero balance. In Chapter 7, creditors may object to the discharge of debt incurred within six months of the date your case is filed. Is the debt contingent, unliquidated or disputed? Contingent debt will be owed only if a certain event occurs. For example, if you co-signed for someone else you will owe only if he or she does not pay. Unliquidated debt has a balance that cannot be determined. If you have injured someone in an automobile accident, the amount of the debt may not be known until all medical expenses are known. Debt is disputed if you and the creditor disagree on the balance. Who is liable? Answer only if you are filing jointly. If debt was incurred before marriage, check the spouse (husband or wife) who owes the debt. If both parties signed for the debt, check joint. If the debt was incurred during the marriage, check community, even if only one spouse signed for it.
Secured Creditors Secured creditors have a lien on property as security for their loan. If you default on the loan, the secured creditor can take the secured property, sell it, and apply the proceeds toward the debt. Examples of secured debt are home mortgages, home equity loans, car loans, department and other store purchases, and finance loans where the finance company has asked you to make a list of property that you own. If a creditor has sued and gotten a judgment against you, it may have a lien on your home. In Chapter 7, you may choose to surrender secured property to the creditor and receive a discharge of the debt. If you want to keep the property, you will need to pay the balance of the debt, usually by making up all missed payments, and making all future payments. If you reaffirm the loan but are later unable to make the payments, the creditor will be able to repossess the secure property, and you will still have to pay any portion of the debt left. In Chapter 13, you may surrender or keep secured property. If you are keeping your home, payments you have missed can be caught up by the plan, but you must make all payments due after the case is filed. Other secured creditors are paid in the plan.
1	Home Mortgage Creditor Name Other			Value of Security $	Debt Amount $		Interest Rate %
	Address			Ch 7 Surrender property Reaffirm Pay without reaffirming Redeem	Ch 13 Surrender property Pay value in plan Pay arrears in plan $_______ Protect a Co-debtor
	City	State	Zip
	Account Number		Secured by Item #	Indicate if there are any of the following and list that party below: Co-debtor Collection agent Attorney Assignee Guarantor
	Secured by (short description)	Date Incurred		Name
	Is the debt Contingent Unliquidated Disputed	Who is liable? Husband Wife Joint Community		Address
	Nature: Deed of Trust Homeowner's Assoc. Judgment Lien Store Charge Purchase Financing Secured Loan Other			City		State	Zip
Note: List VA, FHA and other mortgage guarantors, or you will owe the guarantee if you or anyone who assumes the loan defaults. Homeowners association fees continue to be assessed (and not discharged) from the date the case is filed until foreclosure.
2	Home 2nd Mortgage Creditor Name Other			Value of Security $	Debt Amount $		Interest Rate %
	Address			Ch 7 Surrender property Reaffirm Pay without reaffirming Redeem	Ch 13 Surrender property Pay value in plan Pay arrears in plan $_______ Protect a Co-debtor
	City	State	Zip
	Account Number		Secured by Item #	Indicate if there are any of the following and list that party below: Co-debtor Collection agent Attorney Assignee Guarantor
	Secured by (short description)	Date Incurred		Name
	Is the debt Contingent Unliquidated Disputed	Who is liable? Husband Wife Joint Community		Address
	Nature: Deed of Trust Homeowner's Assoc. Judgment Lien Store Charge Purchase Financing Secured Loan Other			City		State	Zip

Secured Creditors (continued)

3	Car Loan Creditor Name Other			Value of Security $	Debt Amount $		Interest Rate %
	Address			Ch 7 Surrender property Reaffirm Pay without reaffirming Redeem	Ch 13 Surrender property Pay value in plan Pay arrears in plan $_______ Protect a Co-debtor
	City	State	Zip
	Account Number		Secured by Item #	Indicate if there are any of the following and list that party below: Co-debtor Collection agent Attorney Assignee Guarantor
	Secured by (short description)	Date Incurred		Name
	Is the debt Contingent Unliquidated Disputed	Who is liable? Husband Wife Joint Community		Address
	Nature: Deed of Trust Homeowner's Assoc. Judgment Lien Store Charge Purchase Financing Secured Loan Other			City		State	Zip
4	Car Loan Creditor Name Other			Value of Security $	Debt Amount $		Interest Rate %
	Address			Ch 7 Surrender property Reaffirm Pay without reaffirming Redeem	Ch 13 Surrender property Pay value in plan Pay arrears in plan $_______ Protect a Co-debtor
	City	State	Zip
	Account Number		Secured by Item #	Indicate if there are any of the following and list that party below: Co-debtor Collection agent Attorney Assignee Guarantor
	Secured by (short description)	Date Incurred		Name
	Is the debt Contingent Unliquidated Disputed	Who is liable? Husband Wife Joint Community		Address
	Nature: Deed of Trust Homeowner's Assoc. Judgment Lien Store Charge Purchase Financing Secured Loan Other			City		State	Zip
5	Car Loan Creditor Name Other			Value of Security $	Debt Amount $		Interest Rate %
	Address			Ch 7 Surrender property Reaffirm Pay without reaffirming Redeem	Ch 13 Surrender property Pay value in plan Pay arrears in plan $_______ Protect a Co-debtor
	City	State	Zip
	Account Number		Secured by Item #	Indicate if there are any of the following and list that party below: Co-debtor Collection agent Attorney Assignee Guarantor
	Secured by (short description)	Date Incurred		Name
	Is the debt Contingent Unliquidated Disputed	Who is liable? Husband Wife Joint Community		Address
	Nature: Deed of Trust Homeowner's Assoc. Judgment Lien Store Charge Purchase Financing Secured Loan Other			City		State	Zip
6	Car Loan Creditor Name Other			Value of Security $	Debt Amount $		Interest Rate %
	Address			Ch 7 Surrender property Reaffirm Pay without reaffirming Redeem	Ch 13 Surrender property Pay value in plan Pay arrears in plan $_______ Protect a Co-debtor
	City	State	Zip
	Account Number		Secured by Item #	Indicate if there are any of the following and list that party below: Co-debtor Collection agent Attorney Assignee Guarantor
	Secured by (short description)	Date Incurred		Name
	Is the debt Contingent Unliquidated Disputed	Who is liable? Husband Wife Joint Community		Address
	Nature: Deed of Trust Homeowner's Assoc. Judgment Lien Store Charge Purchase Financing Secured Loan Other			City		State	Zip

Secured Creditors (continued)

7	Creditor Name			Value of Security $	Debt Amount $		Interest Rate %
	Address			Ch 7 Surrender property Reaffirm Pay without reaffirming Redeem	Ch 13 Surrender property Pay value in plan Pay arrears in plan $_______ Protect a Co-debtor
	City	State	Zip
	Account Number		Secured by Item #	Indicate if there are any of the following and list that party below: Co-debtor Collection agent Attorney Assignee Guarantor
	Secured by (short description)	Date Incurred		Name
	Is the debt Contingent Unliquidated Disputed	Who is liable? Husband Wife Joint Community		Address
	Nature: Deed of Trust Homeowner's Assoc. Judgment Lien Store Charge Purchase Financing Secured Loan Other			City		State	Zip
8	Creditor Name			Value of Security $	Debt Amount $		Interest Rate %
	Address			Ch 7 Surrender property Reaffirm Pay without reaffirming Redeem	Ch 13 Surrender property Pay value in plan Pay arrears in plan $_______ Protect a Co-debtor
	City	State	Zip
	Account Number		Secured by Item #	Indicate if there are any of the following and list that party below: Co-debtor Collection agent Attorney Assignee Guarantor
	Secured by (short description)	Date Incurred		Name
	Is the debt Contingent Unliquidated Disputed	Who is liable? Husband Wife Joint Community		Address
	Nature: Deed of Trust Homeowner's Assoc. Judgment Lien Store Charge Purchase Financing Secured Loan Other			City		State	Zip
9	Creditor Name			Value of Security $	Debt Amount $		Interest Rate %
	Address			Ch 7 Surrender property Reaffirm Pay without reaffirming Redeem	Ch 13 Surrender property Pay value in plan Pay arrears in plan $_______ Protect a Co-debtor
	City	State	Zip
	Account Number		Secured by Item #	Indicate if there are any of the following and list that party below: Co-debtor Collection agent Attorney Assignee Guarantor
	Secured by (short description)	Date Incurred		Name
	Is the debt Contingent Unliquidated Disputed	Who is liable? Husband Wife Joint Community		Address
	Nature: Deed of Trust Homeowner's Assoc. Judgment Lien Store Charge Purchase Financing Secured Loan Other			City		State	Zip
10	Creditor Name			Value of Security $	Debt Amount $		Interest Rate %
	Address			Ch 7 Surrender property Reaffirm Pay without reaffirming Redeem	Ch 13 Surrender property Pay value in plan Pay arrears in plan $_______ Protect a Co-debtor
	City	State	Zip
	Account Number		Secured by Item #	Indicate if there are any of the following and list that party below: Co-debtor Collection agent Attorney Assignee Guarantor
	Secured by (short description)	Date Incurred		Name
	Is the debt Contingent Unliquidated Disputed	Who is liable? Husband Wife Joint Community		Address
	Nature: Deed of Trust Homeowner's Assoc. Judgment Lien Store Charge Purchase Financing Secured Loan Other			City		State	Zip

Priority Creditors

The law gives priority to Federal and state taxes which meet any one or more of these criteria: 1. The return for the tax was due within 3 years before your case is filed. Income tax returns are usually due on April 15 after the end of the tax year, but they could be due on April 16th if the 15th fell on a Sunday, or months later if you got an extension. 2. The return was not filed or was filed within 2 years before your case is filed. (This does not apply to Chapter 13, but any unfiled returns must be filed before the confirmation hearing or the case will be dismissed.) 3. If the tax is based on an assessment (from audits, etc) the assessment was made within 240 days before your case is filed. 4. All withholding (Form 940) and unemployment (Form 941) tax on your employees, and the 100% penalty for withholding or unemployment taxes owed by a corporation you controlled. Note: The time you were in a previous Chapter 7 or Chapter 13, plus an additional 180 days, will not count in calculating any of the above time periods. In Chapter 7, priority tax claims will not be discharged. In chapter 13, your plan must pay priority tax claims. If IRS or the state has filed a lien, the taxes will be secured by property you own. This lien will remain even if the tax is discharged. The following kinds of debt are also given priority and will be paid before other debt in Chapter 7: 1. Wages, salaries, and commissions, including vacation, severance, and sick leave pay which you owe to your employees, up to $2,000 per employee, earned within 90 days before the bankruptcy is filed, or business ceased, whichever occurred first. 2. Money owed to employee benefit plans for services rendered within 180 days before the bankruptcy was filed or the business ceased, whichever occurred first. 3. Money you owe to certain farmers and fishermen up to $2,000 per farmer or fisherman. 4. Up to $900 for purchase, lease, or rental deposits for personal, family, or household services not delivered or provided.
11
	Type of claim: Taxes Wages, salaries & commissions Employee benefit plan debt Debt to farmers or fishermen Deposits				Is the debt Contingent Unliquidated Disputed		Who is liable? Husband Wife Joint Community
	Creditor Name Internal Revenue Service				Indicate if any party below is connected with the account and list below Co-debtor Collection agent Attorney Assignee Guarantor
	Address				Name
	City		State	Zip	Address
	Account Number (For taxes give Taxpayer ID, or SSN)				City			State	Zip
	Tax Year	1040, 940, 941	Date return filed	Date assessed	Tax amount	Interest	Penalty	Lien filed? Give county.



12
	Type of claim: Taxes Wages, salaries & commissions Employee benefit plan debt Debt to farmers or fishermen Deposits				Is the debt Contingent Unliquidated Disputed		Who is liable? Husband Wife Joint Community
	Creditor Name Arizona Department of Revenue				Indicate if any party below is connected with the account and list below Co-debtor Collection agent Attorney Assignee Guarantor
	Address				Name
	City		State	Zip	Address
	Account Number (For taxes give Taxpayer ID, or SSN)				City			State	Zip
	Tax Year	1040, 940, 941	Date return filed	Date assessed	Tax amount	Interest	Penalty	Lien filed? Give county.



13
	Type of claim: Taxes Wages, salaries & commissions Employee benefit plan debt Debt to farmers or fishermen Deposits				Is the debt Contingent Unliquidated Disputed		Who is liable? Husband Wife Joint Community
	Creditor Name				Indicate if any party below is connected with the account and list below Co-debtor Collection agent Attorney Assignee Guarantor
	Address				Name
	City		State	Zip	Address
	Account Number (For taxes give Taxpayer ID, or SSN)				City			State	Zip
	Tax Year	1040, 940, 941	Date return filed	Date assessed	Tax amount	Interest	Penalty	Lien filed? Give county.

Unsecured Creditors

14	Creditor Name			Setoff: Does the creditor owe you money which may reduce the debt? No Yes, give amount: $	Debt Amount $
	Address			Indicate if any party below is connected with the account and list below Co-debtor Collection agent Attorney Assignee Guarantor
	City	State	Zip	Name
	Account Number	Date Incurred		Address
	Reason for debt Charge card Loan Rent Liability from accident Other	Is the debt Contingent Unliquidated Disputed		City	State	Zip
	Who is liable? Husband Wife Joint Community			Check to protect the above co-debtor in Ch 13 & give interest rate: %
15	Creditor Name			Setoff: Does the creditor owe you money which may reduce the debt? No Yes, give amount: $	Debt Amount $
	Address			Indicate if any party below is connected with the account and list below Co-debtor Collection agent Attorney Assignee Guarantor
	City	State	Zip	Name
	Account Number	Date Incurred		Address
	Reason for debt Charge card Loan Rent Liability from accident Other	Is the debt Contingent Unliquidated Disputed		City	State	Zip
	Who is liable? Husband Wife Joint Community			Check to protect the above co-debtor in Ch 13 & give interest rate: %
16	Creditor Name			Setoff: Does the creditor owe you money which may reduce the debt? No Yes, give amount: $	Debt Amount $
	Address			Indicate if any party below is connected with the account and list below Co-debtor Collection agent Attorney Assignee Guarantor
	City	State	Zip	Name
	Account Number	Date Incurred		Address
	Reason for debt Charge card Loan Rent Liability from accident Other	Is the debt Contingent Unliquidated Disputed		City	State	Zip
	Who is liable? Husband Wife Joint Community			Check to protect the above co-debtor in Ch 13 & give interest rate: %
17	Creditor Name			Setoff: Does the creditor owe you money which may reduce the debt? No Yes, give amount: $	Debt Amount $
	Address			Indicate if any party below is connected with the account and list below Co-debtor Collection agent Attorney Assignee Guarantor
	City	State	Zip	Name
	Account Number	Date Incurred		Address
	Reason for debt Charge card Loan Rent Liability from accident Other	Is the debt Contingent Unliquidated Disputed		City	State	Zip
	Who is liable? Husband Wife Joint Community			Check to protect the above co-debtor in Ch 13 & give interest rate: %

Unsecured Creditors (Continued)

18	Creditor Name			Setoff: Does the creditor owe you money which may reduce the debt? No Yes, give amount: $	Debt Amount $
	Address			Indicate if any party below is connected with the account and list below Co-debtor Collection agent Attorney Assignee Guarantor
	City	State	Zip	Name
	Account Number	Date Incurred		Address
	Reason for debt Charge card Loan Rent Liability from accident Other	Is the debt Contingent Unliquidated Disputed		City	State	Zip
	Who is liable? Husband Wife Joint Community			Check to protect the above co-debtor in Ch 13 & give interest rate: %
19	Creditor Name			Setoff: Does the creditor owe you money which may reduce the debt? No Yes, give amount: $	Debt Amount $
	Address			Indicate if any party below is connected with the account and list below Co-debtor Collection agent Attorney Assignee Guarantor
	City	State	Zip	Name
	Account Number	Date Incurred		Address
	Reason for debt Charge card Loan Rent Liability from accident Other	Is the debt Contingent Unliquidated Disputed		City	State	Zip
	Who is liable? Husband Wife Joint Community			Check to protect the above co-debtor in Ch 13 & give interest rate: %
21	Creditor Name			Setoff: Does the creditor owe you money which may reduce the debt? No Yes, give amount: $	Debt Amount $
	Address			Indicate if any party below is connected with the account and list below Co-debtor Collection agent Attorney Assignee Guarantor
	City	State	Zip	Name
	Account Number	Date Incurred		Address
	Reason for debt Charge card Loan Rent Liability from accident Other	Is the debt Contingent Unliquidated Disputed		City	State	Zip
	Who is liable? Husband Wife Joint Community			Check to protect the above co-debtor in Ch 13 & give interest rate: %
22	Creditor Name			Setoff: Does the creditor owe you money which may reduce the debt? No Yes, give amount: $	Debt Amount $
	Address			Indicate if any party below is connected with the account and list below Co-debtor Collection agent Attorney Assignee Guarantor
	City	State	Zip	Name
	Account Number	Date Incurred		Address
	Reason for debt Charge card Loan Rent Liability from accident Other	Is the debt Contingent Unliquidated Disputed		City	State	Zip
	Who is liable? Husband Wife Joint Community			Check to protect the above co-debtor in Ch 13 & give interest rate: %

Unsecured Creditors (Continued)

23	Creditor Name			Setoff: Does the creditor owe you money which may reduce the debt? No Yes, give amount: $	Debt Amount $
	Address			Indicate if any party below is connected with the account and list below Co-debtor Collection agent Attorney Assignee Guarantor
	City	State	Zip	Name
	Account Number	Date Incurred		Address
	Reason for debt Charge card Loan Rent Liability from accident Other	Is the debt Contingent Unliquidated Disputed		City	State	Zip
	Who is liable? Husband Wife Joint Community			Check to protect the above co-debtor in Ch 13 & give interest rate: %
24	Creditor Name			Setoff: Does the creditor owe you money which may reduce the debt? No Yes, give amount: $	Debt Amount $
	Address			Indicate if any party below is connected with the account and list below Co-debtor Collection agent Attorney Assignee Guarantor
	City	State	Zip	Name
	Account Number	Date Incurred		Address
	Reason for debt Charge card Loan Rent Liability from accident Other	Is the debt Contingent Unliquidated Disputed		City	State	Zip
	Who is liable? Husband Wife Joint Community			Check to protect the above co-debtor in Ch 13 & give interest rate: %
25	Creditor Name			Setoff: Does the creditor owe you money which may reduce the debt? No Yes, give amount: $	Debt Amount $
	Address			Indicate if any party below is connected with the account and list below Co-debtor Collection agent Attorney Assignee Guarantor
	City	State	Zip	Name
	Account Number	Date Incurred		Address
	Reason for debt Charge card Loan Rent Liability from accident Other	Is the debt Contingent Unliquidated Disputed		City	State	Zip
	Who is liable? Husband Wife Joint Community			Check to protect the above co-debtor in Ch 13 & give interest rate: %
26	Creditor Name			Setoff: Does the creditor owe you money which may reduce the debt? No Yes, give amount: $	Debt Amount $
	Address			Indicate if any party below is connected with the account and list below Co-debtor Collection agent Attorney Assignee Guarantor
	City	State	Zip	Name
	Account Number	Date Incurred		Address
	Reason for debt Charge card Loan Rent Liability from accident Other	Is the debt Contingent Unliquidated Disputed		City	State	Zip
	Who is liable? Husband Wife Joint Community			Check to protect the above co-debtor in Ch 13 & give interest rate: %