Section 5 – Statement of Financial Affairs (continued)
7. Legal Actions, Administrative Proceedings, Court Actions, Executions,
Attachments, or Governmental Audits
List all legal actions, proceedings, investigations, arbitrations, mediations, and audits by
federal or state agencies within the last year in which the debtor was involved.
8. Assignments and Receiverships
List (1) any property in the hands of an assignee for the benefit of creditors within the last
120 days, and (2) any property in the hands of a custodian, receiver, or court-appointed
official within the last year.
9. Gifts and Charitable Contributions
List all gifts or charitable contributions of $1,000 or more made within the last 2 years.
10. Losses (fire, theft, or other casualty in last year)
List all losses from fire, theft, or other casualty within the last year.
11. Payments Related to Bankruptcy (last year)
List all payments made or property transferred by or on behalf of the debtor within the last
year to any persons, including attorneys, for consultation concerning debt consolidation or
restructuring, seeking bankruptcy relief, or iling a bankruptcy case.
12. Self-Settled Trusts of Which the Debtor is a Beneficiary (last 10 years)
List all payments or property transfers made by the debtor or by someone acting on the
debtor's behalf within the last 10 years to a self-settled trust or similar device.
13. Other Transfers (last 2 years, outside ordinary course of business)
List all other property, other than property transferred in the ordinary course of the debtor's
business or financial affairs, transferred either absolutely or as a security within the last 2
years.
14. Previous Addresses (last 3 years)
List all previous addresses used by the debtor within the last 3 years.
15. Health Care Bankruptcies
Fill in the information below If the debtor is primarily engaged in offering services and
facilities for diagnosing or treating injury, deformity, or disease, or providing surgical,
psychiatric, drug treatment, or obstetric care.
16. Pension or Profit-Sharing Plan (last 6 years)
List any ERISA, 401(k), 403(b), or other pension or profit-sharing plans made available by
the debtor as an employee benefit within the last 6 years.
17. Closed Financial Accounts (last year)
List all financial accounts or instruments held in the debtor's name or for the debtor's benefit
that were closed, sold, moved, or transferred within the last year.
18. Safe Deposit Boxes (last year)
List any safe deposit box or other depository for securities, cash, or other valuables the
debtor now has or did have within the last year.
19. Off-Site Storage (last year)
List any property kept in storage units or warehouses within the last year.
20. Property Held for Another Entity
List any property that the debtor holds or controls that is owned by another entity. (Do not
list leased or rented property.)
21. Environmental Proceedings
List any judicial or administrative proceedings, including settlements and orders, under any
environmental law to which the debtor has been a party. Report all known proceedings,
regardless of when they occurred. Include the case title and the case number, the court or
agency, the nature of the case, and the status.
Environmental law means any federal, state, or local statue or regulation regulating pollution,
contamination, releases of hazardous or toxic substances, wastes or material into the air,
land, soil surface water, ground water, or other medium, including, statutes or regulations
controlling the cleanup of these substances, wastes, or material.
Site means any location, facility, or property as defined under any environmental law,
whether you own, operate, or utilize it or used to own, operate, or utilize it, including disposal
sites.
Hazardous material means anything an environmental law defines as a hazardous waste,
hazardous substance, toxic substance, hazardous material, pollutant, or contaminant or
similar term.
22. Environmental Notices
List every site for which the debtor has received notice by a governmental unit that it may be
liable under or in violation of an environmental law. Include the name and address of the
governmental unit, the date of the notice, and, if known, the environmental law.
23. Hazardous Material Release
List the name and address of every site for which the debtor has notified a governmental unit
of a hazardous material release. Include the name and address of the governmental unit to
which the notice was sent, the date of the notice, and, if know, the environment law.
24. Other Business Interests
List any business for which the debtor was an owner, partner, member, or otherwise a person
in control within the last 6 years.
25. Books, Records, and Financial Statements
List all accountants and bookkeepers who maintained the debtor's books and records within
the last 2 years.
26. Audits and Financial Statements
List all firms or individuals who, within the last 2 years, have audited, compiled, or reviewed
the debtor's books of account and records or prepared a financial statement.
27. Possession of Books and Records
List all firms or individuals who are in possession of the debtor's books of account and
records. If the records are not available, explain.
28. Financial Statements
List all financial institutions, creditors, and other parties, including mercantile and trade
agencies, to whom a financial statement was issued by the debtor within the last 2 years.
29. Inventories
Provide details of the two most recent inventories taken of the debtor's property within the last 2 years.
30. Current Officers, Directors, Partners, and Shareholders
List the debtor's officers, directors, managing members, general partners, members in control, controlling shareholders, or other people currently in control of the debtor.
31. Former Officers, Directors, Partners, and Shareholders
List the debtor's officers, directors, managing members, general partners, members, or
shareholders who were in control of the debtor within 1 year before the filing of the case but
who no longer hold these positions.
32. Payments, Distributions, or Withdrawals to Insiders
List all withdrawals or distributions credited or given to an insider, including compensation
in any form, draws, bonuses, loans, credits on loans, stock redemptions, options exercised
within the last year.
33. Tax Consolidation Group
If the debtor has been a member of a consolidated group for tax purposes within the last 6
years, list the name and employer identification number of the parent corporation.
34. Pension Funds
If the debtor, as an employer, has been responsible for contributing to a pension fund at any
time during the last 6 years, list the name and employer identification number of the fund.
