Questionnaire #1 - Basics & Income

Please complete your personal Bankruptcy Questionnaire for Information and free consultation about your individual circumstances and unique situation.

This information is input into our bankruptcy program which will result in a print out for the court if you should decide to file. It puts all the information in the order I review it. By using this, you can see a financial overview of your particular circumstances at no charge to you.

With this evaluation in your hands, you are able to use the overall information to BEGIN your best financial route even if you decide bankruptcy is not your best route.

This Form cannot be submitted until the missing fields (labelled below in red) have been filled in
Questionnaire 1 - Voluntary Petition & Means Test
Hello! Please provide as much information as you would like for a prompt and complete search. Thank-you, Rica
How did you hear about us?
Friends and Family Internet Search Craigslist Advertisement Penny Saver Advertisement
Did you filed bk in the past eight yrs?
YES NO
If yes, what year?
If yes, what city, state and when
If yes, what is the case number?
E-mail Address*
Preference for the court fees?
PAY IN FULL $335 IN PAYMENTS WILL REQUEST A FEE WAIVER
Do you have a counseling certificate complete?
NO, what is it? NO, I know what it is. https://www.debtorcc.org/ YES, I have one.
Your Full Name (please include middle)*
All other names you have used in the last 8 years Include your married or maiden names.
Last 4 of social ONLY (not full social)
Any business names and Employer Identification Numbers (EIN) you have used in the last 8 years Include trade names and doing business as names
Physical Street Address*
City, State *
Your zip code*
Mailing Address including zip - if different
What county do you live in? *
Have you lived in this area for 181+ days
Best Phone
Chapter of Bankruptcy	Chapter 7 Chapter 11 Chapter 12 Chapter 13
Do you rent? Has your landlord obtained an eviction judgment against you?	No. I don't rent. Yes. I rent and NO judgment. Yes. I rent and I have an eviction judgment.
Debtor's Employer Name (or enter "none" and skip related questions)
Debtor's Employer Address, City and Zip
Unemployment, if any $
Social Security, if any $
Government Assistance (Describe and $)
Family support payments that you, a non-filing spouse, or a dependent regularly receive Include alimony, spousal support, child support, maintenance, divorce settlement, and property settlement. $
Pension or Retirement $
Debtor's Occupation
When did you start this job?
Gross Wages Monthly $*
Overtime $
Tax, Medicare, and Social Security deductions
Mandatory contributions for retirement plans
Voluntary contributions for retirement plans
Required repayments of retirement fund loans $
Your insurance withheld monthly $
Domestic support obligations $
Other withholdings amount & description $
Union dues $
List any other source of income & $
If you are including expenses paid by others please list their name & the gift income from them
Expected 10 % change in income/expense in the 12 mths?	YES NO
If yes, please explain the change
First Name, Age, Relationship of Dependents
MARRIED/SINGLE*	---Select---Never Married (SKIPPED TO END) Widowed Divorced Legally Separated Living Apart, Not filing joint Living Apart, Filing joint Living Together, Not filing joint Living Together, Filing joint
Spouse's full name, if married
List any other first, middle or last name used in the past 8 years
Last 4 of social ONLY (not full social)
Spouse's physical address - if different
Spouse's mailing address, if different
Unemployment, if any $
Unemployment, if any $
Social Security, if any $
Government Assistance, if any - Type & $
Family Support, if any $
Pension or Retirement $
Spouse's Occupation
When did your spouse start this job?
If any, Spouse's Employer Employer Name (or enter "none" and skip related questions)
Spouse's Employer's Address, City, State, Zip
Gross Wages Monthly $
Overtime $
Tax, Medicare, and Social Security deductions
. Mandatory contributions for retirement plans
Voluntary contributions for retirement plans
d. Required repayments of retirement fund loans
Spouse's insurance withheld monthly
Domestic support obligations
Spouse's union dues monthly
Spouse's other withholdings amount and description
List any other source of income & amount
Do you expect a 10% change in income in the next 12 months?
YES NO
What do you expect to change? Note if spouse if so.
Anything else you would like to say about income

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Rica J. Gilmore, Broker, Realtor® 

• Virginia License VA #0225235314 
• Rica Jo Ann Gilmore,​ ​Realtor®​ ​ ​
• Graduate, REALTOR® Institute
• ​​Rica Realty​​​ ​​​VA #0225235314​
• ​Accredited Buyer's Agent
• ​Seller Representative Specialist​ 
• ​REALTORS® Commitment to Excellence​
• ​Military Relocation Professional
• Seniors Real Estate Specialist®
• Short Sales and Foreclosure Resource
• Pricing Strategy Advisor
• Home Measurement Specialist
• ​Real Estate Negotiation Expert​
• ​Certified Team Specialist​

Rica Jo Ann Gilmore, Broker  Realtor®144 Shoe Lane, Newport News, VA 23606 1-757-932-7422  

North Carolina License NC 305512:  Rica J. Gilmore, Broker The Virtual Realty Group - Independent Firm Main office: 8116 Arlington Blvd, Ste 115, Falls Church, VA 22042 Telephone 1-888-407-2410 

The listings data displayed on this medium comes in part from the Central Virginia Regional MLS, (CVR MLS) and has been authorized by participating listing Broker Members of Central Virginia Regional MLS, (CVR MLS) for display. Central Virginia Regional MLS, (CVR MLS)  listings are based upon Data submitted by its Broker Members, and Central Virginia Regional MLS, (CVR MLS) therefore makes no representation or warranty regarding the accuracy of the Data. All users of Central Virginia Regional MLS, (CVR MLS) listings database should confirm the accuracy of the listing information directly with the listing agent.

CVR MLS and/or Rica J. Gilmore and information is protected under federal copyright laws. Federal law prohibits, among other acts, the unauthorized copying or alteration of, or preparation of derivative works from, all or any part of copyrighted materials, including certain complications of Data and information. COPYRIGHT VIOLATORS MAY BE SUBJECT TO SEVERE FINES AND PENALTIES UNDER FEDERAL LAW.

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