READ THIS BEFORE USING DOCUMENT This Chapter 11 debtor questionnaire provides a list of preliminary information required for commencing a Chapter 11 proceeding. The Questionnaire should be completed by the debtor's management and personnel so that bankruptcy counsel can complete the petition and assess relief that may be necessary early in the case and at later stages. The Questionnaire has links to Standard Documents that include forms for providing detailed information necessary to file for Chapter 11 with important drafting notes and considerations. The drafting notes include specific considerations under the Local Bankruptcy Rules for Delaware and the Southern District of New York (SDNY) Bankruptcy Courts. For other bankruptcy jurisdictions, counsel should review the local bankruptcy rules particular to that court Debtor Questionnaire1. Name of debtor(s) (exactly as it appears on certificate of incorporation):2. If applicable, any other names under which the debtor(s) has done business during the past 8 years:3. Were prior bankruptcy cases filed by or against the debtor within the last 8 years?Select OneYesNoIf yes, provide the District, date of filing and case number4. Are any bankruptcy cases pending or being filed by a business partner or affiliate of the debtor?Select OneYesNoIf yes, list all debtor names, the relationship, the district, when the case was filed and the case number, if known5. Debtor's principal place of business, including street address and county of residence6. Debtor's mailing address, if different from principal place of business7. Location of Debtor's principal assets, if different from principal place of business8. Debtor's federal Employer Identification Number(s):9. State of Incorporation10. Date of Incorporation Date Format: MM slash DD slash YYYY 11. Telephone Number12. Fax Number13. Description of Business(es) and History of debtor (attach separate sheet(s) using annexed Schedule14. North American Industry Classification System's (NAICS) 4 digit code that best describes the debtor15. A concise statement setting forth the reasons for the debtor's financial difficulties and how projected future operations will address these difficulties (attach separate sheet(s) using Schedule 1)16. Fiscal Year Date Format: MM slash DD slash YYYY 17. Does the debtor own or possess any real property or personal property that needs immediate attention?Select OneYesNoIf yes, answer the following questions concerning why the property needs immediate attention:18. Does the property pose or is it alleged to pose a threat of imminent and identifiable public health or safety?Select OneYesNoWhat is the hazard?19. Does the property need to be physically secured or protected from the weather?Select OneYesNo20. Does the property include perishable goods or assets that could quickly deteriorate or lose value without attention (for example, livestock, meat, dairy, produce, or securities related assets or other options)?Select OneYesNoWhat are the perishable assets?21. . Where is the property located (include street address)?22. Is the property insured? If yes, provide the insurance agency, contact name and phone number23. Identify all persons constituting the senior management engaged in the operations of the debtor, their tenure with the debtor, a brief summary of their relevant responsibilities, the amount of stock, if any, of the debtor beneficially owned by each, and the annual compensation paid to each.24. Name and title of officer(s) who will be authorized to sign petition(s) and other documents25. Provide a corporate resolution of the Board of Directors authorizing the filing 26. Prepare an alphabetized list of all of the debtor(s)' creditors. Set forth names and addresses, with zip codes, in matrix form. If a debt is owed to a US agency, the debtor must list the particular agency or department and address to which such debt is owing. If there are more than 10 but less than 1000 creditors and equity security holders, the creditor matrix must be filed with the petition. If there are a large number of creditors and parties in interest (over 200 in Delaware or over 250 in the Southern District of New York), a claims and noticing agent will be retained to maintain the creditor matrix. Include trade creditors and: All federal, state and local taxing authorities. Utilities. Parties under contracts, leases (including landlords and tenants) or any other agreements. All other suppliers of goods and services to whom the debtor is or may be indebted. All parties involved in litigation with the debtor. All other parties who may assert contingent, unliquidated and/or disputed claims 27. Prepare a list of the debtor's creditors who have the 20 largest unsecured claims in descending order by the amount of their claims. Omit from this list all insiders, such as officers, directors, stockholders, employees, relatives of principals of the debtor corporation and subsidiary corporations, secured creditors and taxing agencies. For each creditor, list: The name. The address (including the number, street, apartment or suite number, and zip code, if not included in the post office address). The telephone number and email address of the creditor contact. The name(s) of person(s) familiar with the debtor's account. The amount of the claim. The nature of the claim (for example, trade debts, bank loans, professional services and government contracts). An indication of whether the claim is contingent, unliquidated, disputed or partially secured. 28. Prepare a schedule of all leases (such as real estate, office equipment and vehicles) and executory contracts.29. Complete separate questionnaire with respect to each unexpired lease of nonresidential real property (for example, office space and warehouse space) (see Chapter 11 Questionnaire for Unexpired NonResidential Real Property Leases).29. Complete separate questionnaire with respect to each unexpired lease of nonresidential real property (for example, office space and warehouse space) (see Chapter 11 Questionnaire for Unexpired NonResidential Real Property Leases).30. The total number of the debtor's employees is:31. For Collective Bargaining Agreements (CBAs), if any: copies of all collective bargaining agreements to which the debtor is a party. Complete separate schedule summarizing the essential terms of the CBAs. Indicate in narrative form any amendments that have been made to the collective bargaining agreements in the preceding 12 months, the status of negotiations, if any, the identity of the collective bargaining agent, reasons for the need to modify such agreement, and the proposed modified terms. Indicate who on behalf of the debtor is primarily responsible for negotiations with collective unions. 32. Complete separate schedule describing all bank accounts maintained by the debtor. 33. Complete schedule of all pending and threatened lawsuits, including the nature and present status of each pending or threatened action or proceeding against the debtor or its property where a judgment against the debtor or a seizure of its property may be imminent. 34. Complete separate schedule listing all utilities providing service to the debtor(s) (for example, electric, gas and telephone) and the average monthly billing to the debtor(s). 35. Complete form indicating anticipated cash receipts and expenses of operations for the 30-day period immediately after filing. 36. Provide a condensed consolidating (if available) and consolidated balance sheet and financial statement or a summary of estimated assets and liabilities of the debtor(s), as of the closest possible date to the anticipated filing date. The balance sheet need only be as precise as possible and need not be audited. 37. Complete separate form with financial and corporate ownership information on a consolidated basis. 38. Complete schedule summarizing pension plans, if any, to which the debtor(s) is required to make contributions and the current funding status of each plan. 39. Complete schedule summarizing ordinary course of business expenditures for items such as reimbursement of employee expenses, corporate credit card charges and monthly insurance premiums for property, liability and health insurance that may not have been paid for the 60-day period prior to filing. 40. If applicable, complete schedule listing all property of the debtor in the possession or custody of any custodian, public officer, mortgagee, pledgee, assignee of rents or secured creditor or agent for any such person, including the name, address, telephone number and contact person, and the court, if any, in which a proceeding relating thereto is pending. 41. The location of the debtor's principal assets is:42. The location of the debtor's principal place of business is:43. The location of the debtor's books and records, including the name, address and telephone number of a person[s] having custody, is:44. If applicable, the location, nature and value of the debtor's assets held outside of the US is:45. If applicable, prepare a list of the premises leased by the debtor from which the debtor operates its business. 46. Complete schedule listing the five largest secured creditors of the debtor in order of amount. Include the name and address, telephone number, and name of the person familiar with the debtor's account, together with the amounts of their respective claims, and a brief description of the collateral (and value of collateral) securing such claims. In addition, please provide all supporting documentation (such as loan and security documents, UCC and other perfecting filings) for each listed secured claim. 47. Complete schedule listing the number and classes of shares of stock, debentures, or other securities of the debtor that are publicly held, and the number of holders thereof. List separately those held by each of the debtor's officers and directors and the amounts so held. SCHEDULE 1 A. Brief history of the debtor's business and reasons for debtor's financial difficulties. B. How projected future operations will address and resolve these difficulties. Attach Your FilesCommentsThis field is for validation purposes and should be left unchanged. This iframe contains the logic required to handle Ajax powered Gravity Forms.