Form 26-5

Pattern Interrogatories in Aid of Judgment—
Individual Debtor

[Short Form]

1.State the following information.

a.Full legal name; please also include any other names you have ever used:

b.Date of birth:

c.Social Security number:

d.Driver’s license number and issuing state:

e.Business address and telephone number:
   City, state, zip:

f.Residence address and telephone number:
   City, state, zip:

2.Do you have an ownership interest or a leasehold interest in any real estate?

If so, then state, with respect to each parcel, the street address, a full legal description (use any attachments if necessary), a description of each structure or improvement, the name and address of any other person who has an ownership interest in the property, the ownership of the property as stated in documents of title, the recording reference and present location of each document of title, the present value of your equity interest in each property, and whether you have designated the parcel as your homestead.

3.Is any of the real property owned by you encumbered by any type of lien or real estate mortgage?

If so, then state, with respect to each parcel, a description of the property encumbered, the nature or type of encumbrance, the date of encumbrance, the name and address of the holder of the encumbrance, the amount of consideration received for the encumbrance, and the date and place of recordation of the encumbrance.

4.If you own your own home, please state the date of purchase, the purchase price, and the amount of the monthly payment. If you rent, state the amount of your monthly rent payment.

a.Date of purchase:

b.Purchase price:

c.Monthly house/rent payment:

5.How many vehicles do you own (including cars, trucks, motorcycles, boats, air­craft, or trailers)?

With reference to each, please state the year, make, model, license number, motor num­ber, serial number, present or usual location, and estimated value.

6.Are you currently married? If so, please state your spouse’s full name.

7.Please state the following information about each checking or savings account that you maintain:

a.Name and address of institution:

b.Account number:

c.Authorized signatures:

d.Present balance:

8.Have you deposited funds or had anyone deposit your funds in any savings, trust, or checking account, whether such account is personal, for business, or held jointly with someone else?

If so, please state the following information about each account:

a.Name and address of institution:

b.Account number:

c.Name on account:

d.Authorized signatures:

e.Present balance:

9.Do you own any stocks, bonds, or other securities of any class in any government, governmental agency, company, firm, or corporation?

If so, please state the name and address of each organization in which the interest is owned, the description and serial or certificate number of each security, and the date and method of acquisition of the security. Please state the name and address of each person, firm, or corporation from which the security was acquired or with whom any joint ownership or community interest is shared, the present location of the security, and the name and address of each person having custody of the security. Please state the name and address of any person, firm, or corporation to whom securities are pledged or mortgaged or subject to an option to repurchase.

10.Do you have any claims for money against others by reason of notes, personal loans, claims for damage, or the like?

If so, please give a complete description of each claim, the name and address of the per­son indebted to you, and the amount claimed due.

11.Do you own any collections of any kind (such as coin or stamp collections)?

If so, please give a complete description of each collection, its contents, the estimated present market value, and its exact present location.

12.Do you have access to any safe-deposit box or other depository for securities, cash, or other valuables?

If so, please state for each depository the name and address of the bank or institution in which it is located and of each person having access to the depository, a complete description of items in the depository as of five days ago, and the date you last entered the depository.

13.Have you conveyed or disposed of any property, by sale, gift, or otherwise, in the past two years?

If so, please give a description of each item conveyed or disposed of, the date of con­veyance or disposition, the name and address of the person receiving it, the manner of convey­ance or disposition, and the consideration received.

14.Do you have any ownership interest in any business?

If so, please state the full name and address of each business, the address where the business is conducted, the type of business conducted, your office or position, and the form of business organization. Also state the date you acquired the interest, the exact present value of the interest, and the percentage of the total your interest represents. Please list the full name and address of each officer, director, or partner.

15.Do you have any accounts receivable, including any assigned or disposed of in the last year?

If so, please give the name and address of each person owing you and the amount due from each, the extent to which future accounts receivable were covered, and the amount of consideration received.

16.Have you entered into any transaction with your spouse or any other relative involving a transfer, conveyance, assignment, or other disposition of any of your real or per­sonal property in the past four years, or have you transferred any of your real or personal prop­erty to any other person in consideration of future support in the past four years?

If so, please list a description of each transaction, the date of the transaction, the consid­eration received, and the name and address of any family member or relative involved.

17.Do you have any debts?

If so, for each creditor state the name and address of the creditor, the amount owed, the date the debt was incurred, how the debt was incurred, and the security given.

18.Have you made any payments to any creditors, including any not listed above, within the past four months?

If so, please state the name and address of each creditor, the amount of each payment, and the date of each payment.

19.Do you have any interest in any pension plan, retirement fund, or profit-sharing plan?

If so, please state the name and address of the administrator of the plan, the present value of your interest in the plan, the nature of the plan, a description of the plan, and a description of terms under which you may receive money or property pursuant to the plan.

20.Using the information on your income tax returns for the past two years, please state the source and amount of each item of income listed, the address of the IRS office where the return was filed and the date of filing, the total income received for each year, amounts of any income received but not shown on any tax return, sources of other income shown on each tax return, and the date of receipt of income not shown on the tax returns.

21.Please state all reasons why you have not paid this debt.

22.If our client is willing to accept less than the full amount of the claim against you, how much money would you be able and willing to pay to our client within the next thirty days to settle this matter?

23.If arrangements for a lump-sum settlement cannot be made, please state when you could start making monthly or other periodic payments and how much you are able and will­ing to pay per month toward satisfying this debt.

24.Why are you unable or unwilling to pay more than the amount you listed in the answers to questions 22. and 23.?

The following information is requested in order to help us work out a settlement with you. You are not required to answer the following question.

Please list the amounts of each of your regular monthly bills.

   
[Name of debtor]

SIGNED under oath before me on ___________________________________.

   
Notary Public, State of Texas