Questionnaire #5 - Unsecured Creditors 

Creditor List! This is a very important part of the process. I ask you provide a complete list of who you owe. 

Please see the Bankruptcy Basics Glossary for a complete list of definitions such as secured or unsecured property or debt if you are not sure.

This is one of a few ways to present your list. Lists outside the questionnaire cannot be spreadsheet format.  You can email or fax them all on one entry if that is easier. Whatever method, all details MUST be completed. A creditor without a street address and city with zip code, will not even listed in the draft. 

The importance of the Creditor List is explained in the B6 continuance provided by the Official Form 6 Schedule F Instructions.

Submit as many Questionnaire 5 as necessary to lists everyone. If a creditor is on all three credit reports, please only enter it ONE time.

More than One Collection Agency

If you have more than 1 collection agency (say it is Sears) - just enter the name and address of the collection agency as a new creditor, but do not enter the amount, date opened, or account number, and in the type of debt write "collection for Sears".

This Form cannot be submitted until the missing fields (labelled below in red) have been filled in
Questionnaire 5 - Unsecured Creditors
Hello! Please provide as much information as you would like for a prompt and complete search. Thank-you, Rica
First Name*
Last Name*
Email Address
*
I understand vehicles, home and other secured items do not go on this questionnaire.*
Yes. Continue.
CREDITOR #1 NAME*
Address w/Zip*
Date Incurred*
Acct # (last four)*
Balance $*
Debt Obligation*	Individual Community (add below if not filing) Husband (add below if not filing) Wife (add below if not filing) Joint (add below if not filing)
NON-filing Party
Address w/Zip
Type of Debt*	---Select---A credit card purchases B dental or medical debt C personal loan D cash advance E taxes due F student loan G other
If other, explain
Collection Agency
Address w/Zip
CREDITOR #2 NAME
Address w/Zip
Date Incurred
Acct # (last four)
Balance $
Debt Obligation	Community Individual (add below if not filing) Husband (add below if not filing) Wife (add below if not filing) Joint (add below if not filing)
NON-filing Party
Address w/Zip
Type of Debt	---Select---A credit card purchases B dental or medical debt C personal loan D cash advance E taxes due F student loan G other
If other, explain
Collection Agency
Address w/Zip
CREDITOR #3 NAME
Address w/Zip
Date Incurred
Acct # (last four)
Balance $
Debt Obligation	Individual Community (add below if not filing) Husband (add below if not filing) Wife (add below if not filing) Joint (add below if not filing)
NON-filing Party
Address w/Zip
Type of Debt	---Select---A credit card purchases B dental or medical debt C personal loan D cash advance E taxes due F student loan G other
If other, explain
Collection Agency
Address w/Zip
CREDITOR #4 NAME
Address w/Zip
Date Incurred
Acct # (last four)
Balance $
Debt Obligation	Individual Community (add below if not filing) Husband (add below if not filing) Wife (add below if not filing) Joint (add below if not filing)
NON-filing Party
Address w/Zip
Type of Debt	---Select---A credit card purchases B medical debt C Secured by Home D Secured by Vehicle E Student Loan F personal loan G other
If other, explain
Collection Agency
Address w/Zip
CREDITOR #5 NAME
Address w/ ZIP CODE
Date Incurred
Acct # (last four)
Balance $
Debt Obligation	Individual Community (add below if not filing) Husband (add below if not filing) Wife (add below if not filing) Joint (add below if not filing)
NON-filing Party
Address w/Zip
Type of Debt	---Select---A credit card purchases B dental or medical debt C personal loan D cash advance E taxes due F student loan G other
If other, explain
Collection Agency
Address w/Zip
CREDITOR #6 NAME
Address w/Zip
Date Incurred
Acct # (last four)
Balance $
Debt Obligation	Individual Community (add below if not filing) Husband (add below if not filing) Wife (add below if not filing) Joint (add below if not filing)
NON-filing Party
Address w/Zip
Type of Debt	---Select---A credit card purchases B dental or medical debt C personal loan D cash advance E taxes due F student loan G other
If other, explain
Collection Agency
Address w/Zip
CREDITOR #7 NAME
Address w/Zip
Date Incurred
Acct # (last four)
Balance $
Debt Obligation	Individual Community (add below if not filing) Husband (add below if not filing) Wife (add below if not filing) Joint (add below if not filing)
NON-filing Party
Address w/Zip
Type of Debt	---Select---A credit card purchases B dental or medical debt C personal loan D cash advance E taxes due F student loan G other
If other, explain
Collection Agency
Address w/Zip
CREDITOR #8 NAME
Address w/Zip
Date Incurred
Acct # (last four)
Balance $
Debt Obligation	Individual Community (add below if not filing) Husband (add below if not filing) Wife (add below if not filing) Joint (add below if not filing)
NON-filing Party
Address w/Zip
Type of Debt	---Select---A credit card purchases B dental or medical debt C personal loan D cash advance E taxes due F student loan G other
If other, explain
Collection Agency
Address w/Zip
CREDITOR #9 NAME
Address w/Zip
Date Incurred
Acct # (last four)
Balance $
Debt Obligation	Individual Community (add below if not filing) Husband (add below if not filing) Wife (add below if not filing) Joint (add below if not filing)
NON-filing Party
Address w/Zip
Type of Debt	---Select---A credit card purchases B dental or medical debt C personal loan D cash advance E taxes due F student loan G other
If other, explain
Collection Agency
Address w/Zip
CREDITOR #10 NAME
Address w/Zip
Date Incurred
Acct # (last four)
Balance $
Debt Obligation	Individual Community (add below if not filing) Husband (add below if not filing) Wife (add below if not filing) Joint (add below if not filing)
NON-filing Party
Address w/Zip
Type of Debt	---Select---A credit card purchases B dental or medical debt C personal loan D cash advance E taxes due F student loan G other
If other, explain
Collection Agency
Address w/Zip

PLEASE HIT SUBMIT

THEN NEXT QUESTIONNAIRE

Rica J. Gilmore, Broker, Realtor® 

• Virginia License VA #0225235314 
• Rica Jo Ann Gilmore,​ ​Realtor®​ ​ ​
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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 

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