| How did you hear about us? Check all that apply |
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Verizon Yellow Pages |
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Verizon Superpages.com |
Friend |
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SW Bell Yellow Pages |
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SW Bell Smartpages.com |
Yahoo Yellow Pages |
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Our Website |
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Lawyers.com |
Internet Search |
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Other Explain: |
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| Full Name: |
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| E-Mail: |
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| Spouse's Full Name : |
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Spouse's E-Mail:
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| Address: |
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| County: |
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| Home Telephone: |
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| Cell phone: |
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| Work Telephone: |
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| Fax: |
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| Spouse's Cell Phone: |
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| Spouse's Work Phone: |
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| Occupation: |
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How Long? |
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| Employed By: |
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| Spouse's Occupation: |
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How Long? |
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| Spouse Employed By: |
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| Do you Own or have an interest in a business? |
Yes No |
| If So, list business name and location: |
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Have you ever filed bankruptcy before? |
Yes No |
If So, how many times and when? |
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| Do you have any Dependents? |
Yes No |
Check here if not living with you |
| List Name, Age, Relationship of Dependents |
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Home and Mortgage (1st Lien)
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Resale Value: Mortgage Company: Balance: Int %: Payment:
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Late Fee:
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(Other Lien)
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| Resale Value: Mortgage Company: Balance: Int %: Payment: |
| Late Fee: |
| Are you behind on your home (either lien?) |
Yes No |
| If yes, by how much? |
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| How Many Months? |
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| Do you want to keep your home? |
Yes No |
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| First Vehicle |
| Paid For Leasing Buying |
| Purchased Mo/Yr: Term of Loan Yrs: Year/Make/Model: |
| Creditor: Balance: Value: Int % Payment: |
| Are you behind? Yes No |
| If yes, how much? |
Do you want to keep it ? Yes No |
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| Second Vehicle |
| Paid For Leasing Buying |
| Purchased Mo/Yr: Term of Loan Yrs: Year/Make/Model: |
| Creditor: Balance: Value: Int % Payment: |
| Are you behind? Yes No |
| If yes, how much? |
Do you want to keep it ? Yes No |
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| Third Vehicle |
| Paid For Leasing Buying |
| Purchased Mo/Yr: Term of Loan Yrs: Year/Make/Model: |
| Creditor: Balance: Value: Int % Payment: |
| Are you behind? Yes No |
| If yes, how much? |
Do you want to keep it ? Yes No |
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| Other Creditors with collateral (e.g. furniture, Computers, Appliances, etc.) |
| First Item: Creditor: Balance: Value: Payment: |
| Second Item: Creditor: Balance: Value: Payment: |
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| Unsecured Debt/Balances |
| Master Card/Visa (all) |
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Bank Loans/Credit Lines |
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| AMEX |
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Gasoline Cards |
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| Sears |
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Medical Bills |
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| Other Dept Stores |
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Personal Loans |
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| Finance Companies |
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Pay Day Loans |
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| Student Loans |
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Other |
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Total Unsecured Debt:
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| How many months behind on payments are you, in general? |
| How many months have passed, in general, since you last used credit cards? |
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| MAJOR ASSETS OTHER THAN HOME AND VEHICLES |
| Real Estate |
| Description Value: Debt Owed: Keep/Return: |
| Furniture |
| Description Value: Debt Owed: Keep/Return: |
| Jewelry |
| Description Value: Debt Owed: Keep/Return: |
| Antiques, etc |
| Description Value: Debt Owed: Keep/Return: |
| IRA |
| Description Value: Debt Owed: Keep/Return: |
| Retirement |
| Description Value: Debt Owed: Keep/Return: |
| Insurance |
| Description Value: Debt Owed: Keep/Return: |
| Stocks/Bonds |
| Description Value: Debt Owed: Keep/Return: |
| Business |
| Description Value: Debt Owed: Keep/Return: |
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| Cash/Checking/Savings Accounts |
| Savings $ Checking $ Cash on Hand $ |
| How Often are you paid? |
| Self: Spouse |
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| Average Income Per Pay Period: |
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Self |
Spouse |
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Self |
Spouse |
| Gross wages, salary |
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Worker’s Comp |
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| Estim Overtime |
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Other Income |
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| SS Benefits |
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Describe Other Income |
| Child Support |
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Total Gross Income: |
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| Payroll Deductions |
| FIT, SS, FICA |
Self
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Spouse
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Self
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Spouse
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| Medicare |
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Retirement |
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| Insurance |
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401(k) loan |
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| Other |
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Describe Other Deductions: |
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Total Deductions: |
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Total Monthly Net Income
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Self +
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Spouse
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= Combined |
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= |
| Note: If paid bi-weekly, to obtain monthly income, multiply 1 paycheck by 26 then divide by 12. |
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| AVERAGE MONTHLY LIVING EXPENSES Do not include credit card payments. |
| Rent/Home Mortgage |
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Car/Truck Payments |
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| Taxes Included: |
Recreation |
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| Insurance Included: |
Subscriptions/Reading |
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| Property Taxes (not included) |
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Charitable Contributions |
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| Home Insurance |
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Child Support/Alimony |
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| Life Insurance (not wage deducted) |
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School Expenses |
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| Auto Insurance |
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Child Care Expenses |
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| Home Association Dues |
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Student Loans |
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| Home Maintenance |
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Business Expenses |
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| Electricity |
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Self Employment Taxes |
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| Gas Heat |
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IRS Payments |
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| Water/Sewer/Trash |
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Pet Care |
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| Cable/Internet |
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Other |
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| Telephone (include cell/pager) |
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Other |
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| Food |
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| Clothing |
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TOTAL:
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| Grooming |
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| Laundry/Dry Cleaning |
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Combined Net Income: |
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| Medical Dental |
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Less Expenses: |
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| Transportation (gas, oil, maintenance, etc.) |
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Total Disposable Income: |
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| Are you expecting to receive a tax refund? |
If yes, how much? |
| If you owe taxes , please complete: |
| Year: Owed: Kind: (income, property, etc.) Date return filed |
| Is a tax lien filed |
| Year: Owed: Kind: (income, property, etc.) Date return filed |
| Is a tax lien filed |
| Do you have an installment agreement with the IRS |
| If yes, what is your payment |
Are you Current If no, How many months in default? |
| Did you submit an offer in compromise? |
Date Submitted |
| Date rejected/withdrawn? |
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If any tax returns were audited,
please give years audited and date of any assessments:
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| Tax years audited: |
| PLEASE ANSWER EACH OF THE FOLLOWING QUESTIONS |
| Are any car repossessions currently pending against you? |
Yes No |
| Are any of your past/present real estate notes guaranteed by the FHA/VA or any other guarantor? |
Yes No |
| Have you sold/transferred any item over $500 in the past 5 years? |
Yes No
If yes, Describe
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| Have you ever assumed real estate from someone, or has anyone ever assumed real estate from you? |
Yes No |
| Have you ever been divorced? |
Yes No |
| If Yes, give years of divorce |
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| Have you been ordered to pay any debts/support payments under a divorce/separation agreement? |
Yes No |
| Have you co-signed any loans? |
Yes No |
| If yes, Explain |
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| Have you made any non-deductible contributions to an IRA? THESE MAY NOT BE EXEMPT |
Yes No |
| Have you pledged any household goods to a finance company? |
Yes No |
Do you have any student loans, or are you a guarantor on someone else’s student loan?
NOTE: Most student loans are not dischargeable in bankruptcy. |
Yes No |
| Do you now or ever have owned a business? |
Yes No |
| If yes, briefly explain |
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Have you ever been convicted of a felony or are you currently on probation, parole, or the subject of any
criminal accusations or indictments? |
Yes No |
If Yes, briefly explain
(Criminal Restitution is not dischargeable) |
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Could you sue anyone and collect any money?
(e.g. Personal Injury) |
Yes No |
| Is there a chance you could be entitled to inheritance within the next 6 months? |
Yes No |
| Have you received any cash advances from your credit cards in the past 6 months? |
Yes No |
| If yes, List amount and approximate date of each: |
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| Did you purchase any item over $250 in the past 6 months? |
Yes No |
| If yes describe, giving approximate date of purchase: |
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| Have you transferred the balance of one credit card account to another within the past 9 months? |
Yes No |
| List amount and approximate date of each transfer: |
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| Do you have any overdue child support/alimony payments? |
Yes No |
| If yes, Amount overdue |
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| Are you and/or your spouse’s wages under garnishment at this time? |
Yes No |
| If yes, explain: |
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| Did you ever work with a credit counseling agency? |
Yes No |
| If yes, name of Agency |
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Briefly describe the reasons for your current financial situation:
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NOTE: I advise you NOT to use any credit cards or incur any additional debt unless
absolutely necessary if you intend to file for bankruptcy. Debts incurred after you consult
a bankruptcy attorney could be non-dischargeable.
Please Click Send from your E-mail Client if it pops up.
The form will come to us complete.
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