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Intake Questionnaire - Bankruptcy Lists


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Filing for bankruptcy requires exhaustive information about your credit history, past income tax returns and various other financial forms.  The document below is designed to help collect information about your company and assist your attorney in assessing your company's financial situation in the event of bankruptcy.  If you or your business are filing for bankruptcy or contemplating filing for bankruptcy, you should collect the following documents (if they exist) and provide them to your attorney.

Legal name of Company:                      _________________________

Location of Company headquarters:                 _________________________

                                                      _________________________

                                                      _________________________

Mailing address, if different:                          _________________________

                                                      _________________________

                                                      _________________________

Addresses for other locations:                         _________________________

                                                      _________________________

                                                      _________________________

                                                      _________________________

                                                      _________________________

                                                      _________________________

Telephone number:                             _________________________

E-mail address:                                  _________________________

Federal tax identification number:          _________________________

State tax identification number:             _________________________

Legal status of the Company (corporation,

partnership, sole proprietor, other):                  _________________________

If the Company is a corporation, list:

Number of shares of preferred stock:        _________________________

         Number of shares of common stock:        _________________________

List person(s) with power to vote 20

percent or more of Company's securities:  _________________________

List corporation(s) with power to vote

20 percent or more of Company's

Securities:                                        _________________________

Is the Company publicly held?               _________________________

If publicly held, what is your

SEC File number?                               _________________________

Has the Company used any trade or

assumed names in the last six years?                 _________________________

List all prior bankruptcies, if any:           _________________________

List any pending bankruptcies of partners,

affiliates, officers or guarantors, if any:    _________________________

Name, address, account number of financial

institution(s) where the Company

maintains accounts:                            _________________________

                                                      _________________________

                                                      _________________________

                                                      _________________________

                                                      _________________________

                                                      _________________________

                                                      _________________________

                                                      _________________________

List the amount of insurance on any

real property owned by the Company:      _________________________

Name of agent:                                   _________________________

List the amount of insurance on any

personal property owned by the Company:         _________________________

Name of agent:                                   _________________________

Are you current on payroll taxes

(FICA, withholding, unemployment)?      _________________________

If not, describe status of delinquent taxes: _________________________

                                                      _________________________

                                                      _________________________

                                                      _________________________

Have all applicable tax returns been filed? _________________________

Is any governmental agency conducting

or planning to conduct an investigation

of the Company?                                _________________________

Has any utility threatened to cut off

service to the Company?                       _________________________

Give a brief description of the Company's

business:                                          _________________________

                                                      _________________________

                                                      _________________________

                                                      _________________________

                                                      _________________________

                                                      _________________________

                                                      _________________________

Does the Company have "petty cash?"      _________________________

If so, in what amount?                          _________________________

Name, address, state, zip, phone number

for Company accountant:                      _________________________

                                                      _________________________

                                                      _________________________

                                                      _________________________

                                                      _________________________


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