IN THE UNITED STATES BANKRUPTCY COURT FOR THE WESTERN DISTRICT OF PENNSYLVANIA In Re: Debtor : : : : : : : : : : : Bankruptcy No. Chapter 11 Movant v. Related to Document No. Respondent (if none, then "No Respondent") CHAPTER 13 BUSINESS CASE QUESTIONNAIRE Local Bankruptcy Rule 1007-4 requires chapter 13 debtors that are self-employed (including debtors acting as landlords), to complete and submit this Questionnaire to the Trustee along with all documents set forth in the Checklist which follows the signature page of the Questionnaire. You must answer all items in the Questionnaire. Use a separate page if additional room is needed, but be sure to reference the additional page next to the item you are answering. All information must be complete and organized. Failure to provide detailed and accurate information may result in the Trustee filing a motion to dismiss your case. You must send this completed Questionnaire along with all required attachments to Ronda J. Winnecour, Trustee, U.S. Steel Tower, Suite 3250, 600 Grant Street, Pittsburgh, PA 15219 so that it reaches the Trustee at least fourteen (14) days prior to your first scheduled meeting of creditors. If you fail to do so, the Trustee may require your appearance at an additional meeting or file a motion to dismiss your case. Do not file this Questionnaire with the Clerk of the Bankruptcy Court. The Questionnaire must be dated. The Questionnaire must contain the original signature of all debtors in the case. A copy of the Questionnaire should be kept by the debtor for future reference. If you have questions concerning this Questionnaire, please contact your attorney. Debtor (s)' Name(s) __________________________________________________________________________ Chapter 13 Case No. _________________________________________________________________________ Name of Business ____________________________________________________________________________ List all past names used by Business _____________________________________________________________ ___________________________________________________________________________________________ Location where business is operated _____________________________________________________________ ___________________________________________________________________________________________ Description of Business Activities/Type of Business _________________________________________________ ___________________________________________________________________________________________ What circumstances led you to file this bankruptcy? _________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ PAWB Local Form 5 (07/13) Page 1of 9 American LegalNet, Inc. www.FormsWorkFlow.com How do you expect these circumstances to change so that you will be able to fund a Chapter 13 Plan? _________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ 1. Type of Business Organization, circle one: Corporation Sole Proprietorship Partnership Other Has business ever been incorporated? __________ Yes Date business began ____________________________ Federal ID number (if applicable) __________________ 2. __________ No State ID number __________________ If your business is a Partnership, please answer (a) to (c) below: (a) Names of Partners ___________________________________________________________________ _____________________________________________________________________________________ (b) Percentage of your ownership: Debtor __________ % Joint Debtor __________ % __________ No (c) Is there a written partnership agreement? __________ Yes If yes, please include a copy of the agreement with this Questionnaire when you return it to the Trustee. 3. If your business is a Corporation, please answer (a) to (g) below: (a) Who are the shareholders? ____________________________________________________________ _____________________________________________________________________________________ (b) How many shares have been issued and are outstanding? ________________________ (c) What is your percentage ownership? Debtor __________ % Joint Debtor __________ % (d) State of incorporation ________________________________________________________________ (e) Is the corporation in good standing with the Secretary of State? __________ Yes __________ No If no, why not? ________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ (f) Fair Market Value of Corporate Assets, including going concern value $________________________ Basis of value _________________________________________________________________________ (g) Amount of Corporate Debts $________________________ 4. Is the business cyclical? __________ Yes __________ No If yes, when is the busy season? __________________________________________________________ If yes, when is the slow season? __________________________________________________________ PAWB Local Form 5 (07/13) Page 2 of 9 American LegalNet, Inc. www.FormsWorkFlow.com 5. Do you have an accountant or bookkeeper? __________ Yes __________ No If yes, please provide the name, address and phone number of this individual _______________________ _____________________________________________________________________________________ Do you understand that you are required to file monthly operating reports with the Court and serve the Trustee with a copy by the 15th of each month that you are in bankruptcy? __________ Yes __________ No 6. Are all tax returns which should have been filed to this point in time filed? _______ Yes If no, list years that are delinquent, type of return owed, and entity to which return is owed: Year ________ ________ ________ ________ ________ Entity(s) and Type of Return Due ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ___________________________________