Bankruptcy Questionnaire

1. First Name
2. Last Name
3. DOB


4. First Name (Spouse)
5. Last Name (Spouse)
6. DOB (Spouse)


7. Marital Status:
8. Number of children at home


10. Home Phone
11. Business Phone


13. Street Address
14. City
15. State Select State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming


16. Zip Code
17. E-mail Address

1. Monthly Income

Owned a business in the past year?

1. Yes
2. No

Filed prior Bankruptcies?

1. Yes
2. No

1. Year and chapter of prior bankruptcies

Any credit union loans?

1. Yes
2. No

1. Balance of credit union loans

Any student loans?

1. Yes
2. No

1. Balance of student loans

Has anyone co-signed with you?

1. Yes
2. No

1. Relationship

Any cash advances in the past 90 days?

1. Yes
2. No

1. Amount
2. From

Do you pay or receive child support?

1. Yes
2. No

1. Amount Paid
2. Amount Received

Behind

1. Yes
2. No

Do you owe back taxes?

1. Yes
2. No

1. Federal
2. State
3. Other

1. Rent
2. Own

Complete if you own your residence

1st Liens

1. Monthly Payment
2. Amount Behind
3. Loan Balance (est)
4. Balloon

2nd Liens

1. Monthly Payment
2. Amount Behind
3. Loan Balance (est)
4. Balloon

3rd Liens

1. Monthly Payment
2. Amount Behind
3. Loan Balance (est)
4. Balloon

1. Approximate Total Unsecured Debt

1. Mortgage/Rent
2. Property Tax
3. Property Insurance
4. Utilities
5. Telephone
6. Food
7. Clothing
8. Laundry
9. Medical Expense
10. Vehicle Payments
11. Gas & Oil
12. Vehicle Repair
13. Vehicle Insurance
14. Spouse Support
15. Child Support
16. Child Care
17. Entertainment
18. Miscellaneous
19. Other
20. TOTAL MONTHLY