| How did you hear about us? Check all that apply |
| |
Verizon Yellow Pages |
|
Verizon Superpages.com |
Friend |
|
SW Bell Yellow Pages |
|
SW Bell Smartpages.com |
Yahoo Yellow Pages |
| |
Our Website |
|
Lawyers.com |
Internet Search |
| |
Other Explain:
|
| |
| Full Name: |
|
| E-Mail: |
|
| Spouse's Full Name : |
|
Spouse's E-Mail:
|
|
| Address: |
|
| County: |
|
| Home Telephone: |
|
| Cell phone: |
|
| Work Telephone: |
|
| Fax: |
|
| Spouse's Cell Phone: |
|
| Spouse's Work Phone: |
|
| Occupation: |
|
How Long? |
|
| Employed By: |
|
| Spouse's Occupation: |
|
How Long? |
|
| Spouse Employed By: |
|
| Do you Own or have an interest in a business? |
Yes
No
|
| If So, list business name and location: |
|
Have you ever filed bankruptcy before? |
Yes
No
|
If So, how many times and when? |
|
| Do you have any Dependents? |
Yes
No
|
Check here if not living with you |
| List Name, Age, Relationship of Dependents |
|
Home and Mortgage (1st Lien) |
Resale Value:
Mortgage Company:
Balance:
Int %:
Payment:
|
Late Fee:
|
(Other Lien) |
| Resale Value:
Mortgage Company:
Balance:
Int %:
Payment:
|
| Late Fee:
|
| Are you behind on your home (either lien?) |
Yes
No |
| If yes, by how much? |
|
| How Many Months? |
|
| Do you want to keep your home? |
Yes
No |
| |
| 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 |
| |
| 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 |
| |
| 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 |
| |
| Other Creditors with collateral (e.g. furniture, Computers, Appliances, etc.) |
| First Item:
Creditor:
Balance:
Value:
Payment:
|
| Second Item:
Creditor:
Balance:
Value:
Payment:
|
| |
| Unsecured Debt/Balances |
| Master Card/Visa (all) |
|
Bank Loans/Credit Lines |
|
| AMEX |
|
Gasoline Cards |
|
| Sears |
|
Medical Bills |
|
| Other Dept Stores |
|
Personal Loans |
|
| Finance Companies |
|
Pay Day Loans |
|
| Student Loans |
|
Other
|
|
Total Unsecured Debt:
|
| How many months behind on payments are you, in general?
|
| How many months have passed, in general, since you last used credit cards?
|
| |
| 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:
|
| |
| Cash/Checking/Savings Accounts |
| Savings $
Checking $
Cash on Hand $
|
| How Often are you paid? |
| Self:
Spouse
|
| |
| Average Income Per Pay Period: |
| |
Self |
Spouse |
|
Self |
Spouse |
| Gross wages, salary |
|
|
Worker’s Comp |
|
|
| Estim Overtime |
|
|
Other Income |
|
|
| SS Benefits |
|
|
Describe Other Income
|
| Child Support |
|
|
Total Gross Income:
|
| |
| Payroll Deductions |
| FIT, SS, FICA |
Self |
Spouse |
|
Self |
Spouse |
| Medicare |
|
|
Retirement |
|
|
| Insurance |
|
|
401(k) loan |
|
|
| Other |
|
Describe Other Deductions:
|
| |
Total Deductions:
|
Total Monthly Net Income |
Self + |
Spouse |
= Combined |
| |
|
|
=
|
| Note: If paid bi-weekly, to obtain monthly income, multiply 1 paycheck by 26 then divide by 12. |
| |
| AVERAGE MONTHLY LIVING EXPENSES
Do not include credit card payments. |
| Rent/Home Mortgage |
|
Car/Truck Payments |
|
| Taxes Included:
|
Recreation |
|
| Insurance Included:
|
Subscriptions/Reading |
|
| Property Taxes (not included) |
|
Charitable Contributions |
|
| Home Insurance |
|
Child Support/Alimony |
|
| Life Insurance (not wage deducted) |
|
School Expenses |
|
| Auto Insurance |
|
Child Care Expenses |
|
| Home Association Dues |
|
Student Loans |
|
| Home Maintenance |
|
Business Expenses |
|
| Electricity |
|
Self Employment Taxes |
|
| Gas Heat |
|
IRS Payments |
|
| Water/Sewer/Trash |
|
Pet Care |
|
| Cable/Internet |
|
Other
|
|
| Telephone (include cell/pager) |
|
Other
|
|
| Food |
|
|
|
| Clothing |
|
TOTAL: |
|
| Grooming |
|
|
|
| Laundry/Dry Cleaning |
|
Combined Net Income: |
|
| Medical Dental |
|
Less Expenses: |
|
| Transportation (gas, oil, maintenance, etc.) |
|
Total Disposable Income: |
|
| |
| 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?
|
|
If any tax returns were audited,
please give years audited and date of any assessments:
|
|
|
| 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
|
| 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
|
|
| 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
|
|
| 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
|
|
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)
|
|
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:
|
|
| Did you purchase any item over $250 in the past 6 months? |
Yes
No |
| If yes describe, giving approximate date of purchase:
|
|
| 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:
|
|
| Do you have any overdue child support/alimony payments? |
Yes
No |
| If yes, Amount overdue
|
|
| Are you and/or your spouse’s wages under garnishment at this time? |
Yes
No |
| If yes, explain:
|
|
| Did you ever work with a credit counseling agency? |
Yes
No |
| If yes, name of Agency
|
|
Briefly describe the reasons for your current financial situation:
|
|
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.
|
