QUESTIONNAIRE FOR JUDGMENT DEBTOR EXAMINATION 1. Name of judgment debtor __________________________________________________ 2. Address of judgment debtor _______________________________________________ 3. What is your date of birth? ______________________________________________ 4. Where were you born? _____________________________________________________ 5. What is your Social Security number? _____________________________________ 6. What is your Driver's license number? ____________________________________ 7. What is your occupation? _________________________________________________ 8. Are you employed by someone else? ___ If so, give name, address, and phone number of your employer: _______________________________________________ ________________________________________________________________________ 9. Are you in business for yourself? ___ If so, give name, address, and phone number of your business: _______________________________________________ ________________________________________________________________________ 10. Are you married? ___ If so, give your spouse's full name (including any maiden name, if applicable): ___________________________________________ ________________________________________________________________________ 11. Do you have any children? ___ If so, give name, age and address of each: ________________________________________________________________________ ________________________________________________________________________ 12. Were you married before your current marriage? _____ If so, give the name and address of each former spouse, the date of marriage, and the date of divorce or death: ______________________________________________________ ________________________________________________________________________ ________________________________________________________________________ 13. Do you live in a home? ___ If so, who owns it? ___________________________ 14. Do you have any boarders or tenants? ___ If so, give name and address of each and the amount of rent or other consideration paid each month: ________________________________________________________________________ 15. Do you have any other sources of income? ___ If so, please describe them: ________________________________________________________________________ ________________________________________________________________________ 16. Are your or your spouse or any of your children employed or in business? ___ If so, give the name and address of the empoyment or for each and the salary or income of each: __________________________________________ ________________________________________________________________________ 17. Do you or your spounse have a safe deposit box? ___ If so, give the name and address of the bank or other institution where the safe deposit box is located:_____________________________________________________________ ________________________________________________________________________ 18. Do you have the right to access any safe deposit box not listed above? ... If so, state the name(s) of the owner(s) of the box and the name and address fo the institution where the box is located: ___________________ ________________________________________________________________________ 19. How much cash do you have on your person at this time? $__________________ 20. Do you or your spouse have any deposit, savings, checking, or other accounts at any bank, credit union, savings institution, thrift and loan, or other institution? ___ If so, state the name and address of the institution(s) where the account(s) is/are held and the amount(s) of the balance(s):_____________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ 21. Is there any deposit, savings, checking or other account that you have not described that is subject to your control? ___ Describe: _______________ ________________________________________________________________________ 22. Do you have power of attorney or any other power to sign checks or other instruments for the payment of money on any account? ___ Describe: ________________________________________________________________________ 23. Do you or your spouse own a boat, automobile or other motor vehicle? ___ If so, for each give the manufacturer and model number, the year of the vessel or vehicle, the balance due and owing thereon, and the name of the legal owner: _______________________________________________________ ________________________________________________________________________ 24. Do you or your spouse have any interest in any real estate, land, improvements, etc.? ___ Describe: ______________________________________ ________________________________________________________________________ ________________________________________________________________________ 25. Do you or your spouse have any interest in any stocks, bonds or other securities? ___ Describe: ______________________________________________ 26. Do you or your spouse have any interest in any mortgages or trust deeds on real property? ___ describe: ___________________________________________ ________________________________________________________________________ 27. Do you or your spouse have any interest in any security agreements or liens on personal property? ___ Describe: ______________________________ ________________________________________________________________________ 28. Do you or your spouse have any interest in any promissory notes, drafts, bills of exchange, commercial paper, or any other instruments? ___ Describe: ______________________________________________________________ 29. Do you or your spouse have a judgment against anyone else? ___ Describe: ________________________________________________________________________ 30. Do you or your spouse have any interest in any watch, diamond(s), other jewelry or antiques? ___ Describe: _____________________________________ 31. Do you or your spouse have any interest in any stamp or coin collection? ___ Describe: __________________________________________________________ 32. Do you or your spouse have any interest in any patents, inventions, trademarks, tradenames, or copyrights? ___ Describe: ___________________ ________________________________________________________________________ 33. Do you or your spouse have any interest in any joint ventures, partnerships, or other business enterprises? ___ Describe: _____________ ________________________________________________________________________ 34. Do you or your spouse have any interest in any warehouse receipts, bills of lading, or other documents of title? ___ Describe: __________________ ________________________________________________________________________ 35. Do you or your spouse have any interest in any musical instruments? ___ Describe: ______________________________________________________________ 36. Have you or your spouse pawned any personal property? ___ If so, state the name of the person or company with whom you pawned the property, the address of such person or entity, and the amount necessary to to redeem the personal property from that pawn: __________________________________ ________________________________________________________________________ 37. Do you or your spouse own any other property not listed above? ___________ If so, furnish complete details: _________________________________________ ________________________________________________________________________ ________________________________________________________________________ 38. Are you or your spouse the beneficiary of any trust? ___ If so, furnish complete details: ______________________________________________________ ________________________________________________________________________ 39. Have you or your spouse inherited any money or property? ___ If so, furnish complete details: ______________________________________________ 40. Do you or your spouse have any interest in the estate of any deceased person? ___ If so, furnish complete details: ___________________________ ________________________________________________________________________ 41. Are you or your spouse a party to any pending lawsuit or other proceeding? ___ If so, state the name and address of the Attorney representing you and/or your spouse, the title of the action, the case number, the name of the court in which the action is pending, and the names and addresses of the Attorney(s) for all other parties who have appeared in the action: ________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ 42. Do you or your spouse have any interest in any will? ___ Describe: _______ ________________________________________________________________________ 43. Have you or your spouse assigned any insurance policy, judgment or cause of action? ___ Describe: _______________________________________________ 44. Have you or your spouse filed any fictitious business name statement of limited partnership? ___ If so, under what name? _______________________ ________________________________________________________________________ ________________________________________________________________________ 45. Have you or your spouse transferred any property whithin the past three years? ___ If so, descibe the property and furnish complete details of the transfer: __________________________________________________________ 47. Has any license, franchise or permit been granted or issued to you or your spouse by the federal, state, city, or county government or any agency thereof? ___ If so, furnish complete details: __________________________ ________________________________________________________________________ 48. Do you or your spouse have any insurance? ___ If so, give the name of the insurance company, the amount, type and date of issuanc of each policy, the policy number for each policy and the annual premium paid for each policy: ________________________________________________________________ ________________________________________________________________________ 49. Have you or your spouse obtained any loans against any insurance policy? ___ If so, furnish complete details: ___________________________________ ________________________________________________________________________ 50. Where are these insurance policies kept? _________________________________ 51. Are you or your spouse receiving, or have you or your spouse made any claim for, any payments on an insurance policy such as a life, health, or disability insurance policy? ___ If so, furnish complete details: ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ 52. Does anyone owe you or your spouse any money? ___ If so, furnish complete details: _______________________________________________________________ 53. Where do you and your spouse keep your books and records? ________________ 54. Have you filed a federal or state income tax return for each of the last 5 years? ___ If so, can those returns be inspected at the conclusion of this hearing? __________________________________________________________ 55. Does the federal or state government owe you or your spouse any money, such as a refund on taxes paid? ___ If so, furnish complete details: ________________________________________________________________________ ________________________________________________________________________ 56. Do you or your spouse have an accountant or CPA? ___ If so, set forth the name, address and telephone number of such person(s): __________________ ________________________________________________________________________ 57. What are you and your spouse's average monthly expenses? _________________ ________________________________________________________________________ 58. Are you making any payments to any creditor? ___ If so, furnish complete details: _______________________________________________________________ 59. What are you and your spouse's total liabilities, including the amount of this judgment? _________________________________________________________ 60. What are the names and addresses of your other creditors: ________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ 61. Are there any judgments of record against you? ___ If so, furnish complete details: _______________________________________________________________ ________________________________________________________________________ 62. Has a receiver, trustee, or custodian been appointed for you or your spouse's property? _____________________________________________________ 63. Have you or your spouse ever made an assignment for the benefit of creditors? ___ if so, furnish complete details: ________________________ ________________________________________________________________________ 64. Have your or your spouse ever filed for bankruptcy? ___ If so, furnish complete details: ______________________________________________________ 65. Have you or your spouse furnished a financial statement or loan application or similar document or anyone during the past three years? ___ If so, furnish complete details: ___________________________________ 66. Are you or your spouse a comaker, guarantor, or endorser on any loan or other obligation? ___ if so, furnish complete details: _________________ ________________________________________________________________________ 67. Are you or your spouse unable to pay your debts as they mature? __________ 68. Has any other judgment creditor taken any steps to enforce a judgment against you or your spouse, such as garnishing your wages, levying on bank accounts, conducting a judgment debtor's examination, etc.? _______ If so, furnish complete details: _______________________________________