QUESTIONNAIRE FOR

SELF-EMPLOYED AND BUSINESS RELATED CHAPTER 13 DEBTORS

CASE NUMBER: _____________________________________________________________________________________

DEBTOR'S NAME(S): _________________________________________________________________________________

BUSINESS INFORMATION (Complete separate form for each business):

BUSINESS TELEPHONE NO.: (________) _____________________________

NAME OF BUSINESS OR D/B/A AND TAX ID NO.: _______________________________________________________

NAME(S) OF OTHER BUSINESSES OR D/B/A'S: _________________________________________________________

____________________________________________________________________________________________________

NAME OF ALL NON-PUBLIC ENTITIES INCLUDING CORPORATIONS, GENERAL AND LIMITED PARTNERSHIPS, P.C.'S, P.A.'S, P.L.L.C.'S, L.L.C.'S, AND TRUSTS IN WHICH DEBTOR HAS ANY LEGAL OR EQUITABLE INTEREST:

____________________________________________________________________________________________________

____________________________________________________________________________________________________

DESCRIPTION OF BUSINESS: _________________________________________________________________________

DATE BUSINESS STARTED: _______________________________________

DO YOU RECEIVE COMISSIONS? ____ YES ____ NO

BONUS? ____ YES ____ NO

RENT? ____ YES ____ NO

ROYALTY? ____ YES ____ NO

ATTACH A COPY OF ANY AGREEMENT FOR COMMISSION, BONUS, RENT, ROYALTY, OR OTHER COMPENSATION OR EXPLAIN ON A SEPARATE SHEET AND ATTACH TO THIS QUESTIONNAIRE.

LOCATION (ADDRESS) OF BUSINESS: ________________________________________________________________

____ CHECK HERE IF BUSINESS ADDRESS IS YOUR HOME.

NO. OF EMPLOYEES OR CONTRACT LABORERS (NON-FAMlLY): ________________________________________

DO YOU REGULARLY OBTAIN TRADE CREDIT IN THE OPERATION OF YOUR BUSINESS? ____ YES ____ NO

DO YOU SELL OR SERVE LIQUOR IN YOUR BUSINESS: _________________________________________________

GROSS REVENUE FROM BUSINESS LAST 12 MONTHS: $________________________________________________

DATE: ____________________________

___________________________________ ___________________________________

Debtor's Signature Debtor's Signature