Bankruptcy Interview
Client email address
Debtor Information
You will directed to another page to make payment after submitting this form.
Full Name:
Please enter your name how it appears on your Social Security card (first, middle, last)
Date of Birth:
Social Security Number:
Address:
City, State, Zip code:
County of Residence:
 Phone Number:
i.e. (000) 000-0000
Have you lived in the same county for at least 180 days (6 months)?
If yes, how long ago:
Have you ever filed Bankruptcy?
STOP- if you have filed for Bankruptcy in the last 8 years we
cannot assist you at this time. Please return when at least 8
years have passed since the last filing.
Marital Status:
Joint Debtor Information (if not filing joint, please list only full name of spouse, even if Seperated. If filing Joint,
Complete all information.)
Full Name:
Please enter your name how it appears on your Social Security card (first, middle, last)
Date of Birth:
Social Security Number:
Address:
City, State, Zip code:
County of Residence:
 Phone Number:
i.e. (000) 000-0000
Have you lived in the same county for at least 180 days (6 months)?
If yes, how long ago:
Have you ever filed Bankruptcy?
STOP- if you have filed for Bankruptcy in the last 8 years we
cannot assist you at this time. Please return when at least 8
years have passed since the last filing.
Marital Status:
Previous Addresses (last 5 years)
Address:
City, State, Zip code:
Please provide month and year moved to this address:
 Please provide month and year you left this address:
List additional if needed:
Address:
City, State, Zip code:
Please provide month and year moved to this address:
 Please provide month and year you left this address:
Dependents
Does this
Dependent
live with you?
Other, Please list relationship
Relationship
Please provide Full Name
 Age
Does this
Dependent
live with you?
Other, Please list relationship
Relationship
Please provide Full Name
 Age
Does this
Dependent
live with you?
Other, Please list relationship
Relationship
Please provide Full Name
 Age
Does this
Dependent
live with you?
Other, Please list relationship
Relationship
Please provide Full Name
 Age
Does this
Dependent
live with you?
Other, Please list relationship
Relationship
Please provide Full Name
 Age
Other names used by Debtor
(Please lest all)
Other names used by Joint Debtor
(Please lest all)
Past marriages of Debtor (list all)
Past marriages of Joint Debtor (list all)
Debtor Income
List gross income (before taxes) that you received from employment for each month indicated below. Enter 0, if none.
4 months ago
 6 months ago
2 months ago
 3 months ago
 5 months ago
Last Month
Have you had other income?
If yes, please give source:
How long have you been receiving this
income? (please provide months or years and
click the appropriate box)
Years
Amount received per month:
 $
Months
Joint Debtor Income
List gross income (before taxes) that you received from employment for each month indicated below. Enter 0, if none.
4 months ago
 6 months ago
2 months ago
 3 months ago
 5 months ago
Last Month
Have you had other income?
If yes, please give source:
How long have you been receiving this
income? (please provide months or years and
click the appropriate box)
Years
Amount received per month:
 $
Months
Tax Information
If there was no income for any of the questions below, enter "0"
Joint Debtors YTD Income (on last pay stub)
Debtors YTD Income (on last pay stub)
$
$
2008 Income (as reported on your 2008 Tax return)
2008 Income (as reported on your 2008 Tax return)
$
$
Same as Debtors
Filed taxes together
2007 Income (as reported on your 2007 Tax return)
2007 Income (as reported on your 2007 Tax return)
$
$
Same as Debtors
Filed taxes together
Joint Debtors income (from other sources)
Debtors income (from other sources)
YTD
 2008
YTD
 2008
 2007
2007
$
$
 $
$
$
$
Joint Debtors Employment Information
Debtors Employment Information
Employer
 Unemployed
Employer
 Unemployed
Address (Street, City, State, Zip code)
Address (Street, City, State, Zip code)
Your Position
Your Position
How long have you been employed here:
How long have you been employed here:
Pay frequency:
 Pay frequency
Monthly Expenses
$
 $
$
Homeowners Insurance

Life Insurance

Health Insurance

Auto Insurance

Auto Payments

Child Support

Other (Please describe below)
Food

Clothing

Laundry and Dry cleaning

Medical and Dental

Transportation

Entertainment

Education
Rent or Mortgage

Prop Tax and Insurance

Maintenance

Electricity and Heating

Water and trash

Telephone

Cable
$
 $
$
$
 $
$
$
 $
$
$
 $
$
$
 $
$
$
 $
$
Assets
Please list yard sale value
Lawsuits
$
Household Furniture and Appliances

Bank accounts

Retirement account

Tax Return

Cash on hand

Jewelery

Settlements

Clothing
If yes, please fax/ email/ mail court papers
(instructions for forwarding additional paperwork will be
provided at end of interview)
$
$
Settlements
If you are expecting a settlement please provide the
following:
$
Who are you suing?
$
$
Whether you have received it already or are you
expecting it? (Please list value of settlement under assets)
$
Please describe other assets
$
Bank Accounts (please list all)
Repos/ Foreclosures
Name of Bank
 Name of Lender
Collateral
Name of Bank
Description:
Retirement Accounts
i.e.: 2001 Ford Explorer, or address of real property.
Name
Date if repo/ foreclosure
Name
Property Transfers
Real Estate
First Mortgage

Property Address:

Lender:

Are you in Foreclosure?

Second Mortgage

Lender:
Have you transferred real
property in the past year?
If yes, give property description
and amount received.
$
Payments to creditors
Have you made any lump sum payments of
$5000.00 or more to creditors or family
members for unsecured debt within the past
year?
Will you keep or surrender the property
Yes
No
Autos
If the Auto is paid off, leave "lender" field blank.
Year
Make
 Model
Lender
Year
Make
 Model
Lender
Year
Make
 Model
Lender
Year
Make
 Model
Lender
Interview Complete
-Please print and submit at end of page-
Please print this interview page before submitting!

Your Online Bankruptcy Interview will be complete once you click submit. After you submit the Bankruptcy Interview, you wil be
directed to the payment page. The fee for this service is $200.00. This fee covers the preparation of your Bankruptcy petition.
There is a $299.00 filing that will be paid by you directly to the Bankruptcy court. There are also additional fees for your first and
second counseling certificate. You can use www.hummingbird.org to fulfill your counseling requirement. The fee for the first
certificate is $49.00, the fee for the second certificate is $19.00. Fees are paid at the time you complete the certificate
requirements.

Payment can only be made by using your Debit card.
-WE DO NOT ACCEPT CREDIT CARD PAYMENTS FOR BANKRUPTCY-
If you do not have a debit card please call or email our office to make an appointment.


Below you will be asked how you would like your documents forwarded to you.
Please Fax or email the following documents to our office:
-Credit Report (free at www.anuualcreditreport.com)
-Pay stubs for the last 2 months
-Law suit documentation
-Statements for items not listed on your credit report (i.e. medical bills, etc.)

You can fax to: (562) 634-4184 or email to: customerservice@crystalibarra.com
Crystal Ibarra & associates will prepare the Chapter 7 Bankruptcy petition and all documents
required to file with the Bankruptcy court. We do not file petitions for the client or give legal
advise. The fee for preparing the Chapter 7 Bankruptcy petition is $200.00
Joint Debtor Agrees to terms
Please type your name below to agree with the above terms.
Debtor Agrees to terms
Please type your name below to agree with the above terms.
email my petition
We will email your petition to the email provided on this form.

We mail this petition to the address provided on this form.
Mail my peition
Please only select this option if you must file within 48 hours.
Emergency petition
Crystal Ibarra & Associates
8756 Artesia Blvd Suite 3
Bellflower, CA 90706
Ph: (562) 634-4184
Fx: (562) 634-4184
customerservice@crystalibarra.com