Attorney or Party Name, Address, Telephone and FAX Pro Se Debtor OFFICE OF THE UNITED STATES TRUSTEE LOS ANGELES DIVISION In Re: SUBMIT TO UNITED STATES TRUSTEE ­ DO NOT FILE WITH COURT Case Number: REAL PROPERTY QUESTIONNAIRE FOR PRINCIPAL RESIDENCE Debtor-In-Possession. THIS QUESTIONAIRE IS TO BE FILLED OUT BY DEBTOR(S) FOR THEIR PRINCIPAL RESIDENCE ONLY. USTLA-5 MUST BE USED FOR ALL OTHER OWNED OR LEASED REAL PROPERTY. THE QUESTIONAIRE IS DUE WITHIN 7 DAYS FROM THE FILING OF A BANKRUPTY PETIION. IF ADDITIONAL TIME IS NEEDED, DEBTORS AND THEIR ATTORNEYS SHOULD CONTACT THE U.S. TRUSTEE TRIAL ATTORNEY ASSIGNED TO THEIR CASE TO REQUEST A REASONABLE EXTENSION OF TIME FOR GOOD CAUSE SHOWN. SECTION ONE: PROPERTY OWNED OR BEING PURCHASED BY DEBTOR A. Address of property including county and state in which it is located: B. C. Percentage interest in the property owned by the Debtor: Date of Debtor=s Acquisition of the Property: Purchase Price: $ D. E. Present Fair Market Value: $ State source and basis of the above fair market value: F. State the name of the titleholder of record as of the date of filing the Petition: Effective September 1, 2011 USTLA 5.1 In Re: Debtor. Case No.: SECTION TWO: FINANCIAL STATUS OF OWNED PROPERTY A. List encumbrances of record against the property (e.g. mortgages, judgments): Creditor Name Current Principal Balance Installment Amount Frequency (Mo/Qtr/Yr) 1st: 2nd: 3rd: 4th: Maturity Date Date of Last Payment Number of Delinquent Installments 1st: 2nd: 3rd: 4th: I declare under penalty of perjury that the answers contained in the foregoing Real Property Questionnaire are true and correct to the best of my knowledge, information and belief. Dated: Print Name of Debtor Signature of Debtor 2 Effective September 1, 2011 USTLA-5.1