Name   _____________________________________                                           Case Number  _________________

 

 Date  _______________________

 

 

CHAPTER THIRTEEN BUSINESS QUESTIONNAIRE

As Required By 11 U.S.C. Section 1302 (c)

 

Laurie K. Weatherford, Esq.

Standing Chapter 13 Trustee

P.O. Box 3450  Winter Park, FL  32790

 

 

INSTRUCTIONS:  Complete this entire form using additional pages if necessary.  Include the case number, debtor’s name and the question number on all additional pages.  All financial information, unless otherwise stated, is to be as of the bankruptcy filing date.

 

 

 

 

 

 

 


1.       DESCRIPTION OF BUSINESS

 

  1. Name of business.  ______________________________________________________________

 

  1. Address or location of business.  ___________________________________________________

 

     ___________________________________________________

 

  1. Name of owner(s).  _____________________________________________________________

 

  1. Main product and/or service.  _____________________________________________________

 

e.      Is the business a:

 

sole proprietorship                    partnership                    corporation

sub chapter S corporation                      Federal ID #  ______________________________

 

  1. When did the business begin operations?            ______________________________________

 

h.  Are you leasing office space?                 Yes                  No

 

                  1.  If yes, do you intend to continue with the lease?           Yes                No

i.  Are you leasing any business equipment?                        Yes                  No

 


1.  If yes, list the equipment, the creditor’s name and address, and the terms of the lease on a separate page.

 

  1. Is your business seasonal?                                           Yes                  No

 

1.       If yes, identify the good and bad months.  ___________________________________

 

  1. Have you pledged your receivables, rents, profits, or

other cash as collateral for any loans?                Yes                  No

 

2.   VALUE OF THE BUSINESS (This section must be completed or the Trustee will not recommend confirmation)

 

  1. Describe each asset with a value over $1,000, using a separate page if necessary.  Include the original cost, age and estimated current market value of each asset.
  2. If applicable, estimate the market value of your inventory.                                        $______________
  3. What is the estimated market value of your accounts receivables?                            $______________

 

  1. ESTIMATED VALUE OF THE BUSINESS, INCLUDING INTANGIBLE PROPERTY?

 

$______________

 

3.  DESCRIPTION OF ALL BANK ACCOUNTS TO WHICH YOU HAVE ACCESS

            Use a separate page if necessary.

 

  1. Provide COPIES of bank statements and all cancelled checks for each account for the three months immediately prior to the Chapter 13 filing.
  2. Are you the only authorized signatory(ies) on the account(s)?      Yes                  No

 

1.       If no, specify who else is an authorized signatory.  __________________________________

 

Bank Name

Account No.

Type of Account

Purpose

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

4.  LIST ALL FULL AND PART TIME EMPLOYEES

            Use a separate page if necessary.

 

Name of Employee

Position/Function

Mo. Salary/

Hourly Rate

P=Part  F=Full

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

5.  PAYROLL TAX REPORTS

 

If you have any employees, provide COPIES of IRS form 941 for the 4 quarters prior to filing and State of Florida UCT-6 form for the 6 months prior to filing your Chapter 13 petition.

 

6.       FEDERAL TAX RETURNS

 

Provide COPIES of your personal and business federal tax returns, along with all supporting schedules, for the last three years.  Also include copies of any W-2's or 1099's you received.  If you receive income from tips that is not included on your W-2, include copies of IRS form 4137.

 

7.       LICENSES

 

If applicable to your business, provide COPIES, not originals, of proof of the following:

 

a.       Business license

b.      Seller’s permit

c.       Contractor’s license

d.      Other  _________________________

 

8.       INSURANCE

 

If applicable, provide COPIES of proof of the following:

 

a.       Business operation liability insurance

b.      Worker’s compensation insurance

c.       Vehicle insurance

d.      Liquor liability insurance

e.      Real and/or personal property insurance

f.         Other  _________________________

 

9.       PROFIT AND LOSS STATEMENT

 

Provide COPIES of the two most recent Profit & Loss statements (income statements) for this business. 

 

10.    BALANCE SHEET

 

Provide COPIES of the two most recent balance sheets for this business.

 

11.  STATEMENT OF CASH FLOWS

 

Provide COPIES of the two most recent statement of cash flows for this business.

 

12.  DECLARATION UNDER PENALTY OF PERJURY BY DEBTOR

 

I(we) declare under penalty of Perjury that I(we) have answered all questions and provided all applicable documents pertaining to this business questionnaire in good faith and that said answers and documents are true and correct.

 

 

Name:        _______________________________

 

Signature:  _______________________________             Date:  ___________________________

 

 

 

Name:        _______________________________

 

Signature:  _______________________________             Date:  ___________________________

 

 

 

·        Upon review of submitted documentation, the Trustee may request additional financial information.  Any additional financial documentation requested must be received and reviewed by the Trustee prior to the final 341 meeting.