Galler Bankruptcy Questionnaire

office 770.671.8830
fax 770.671.8840

Bankruptcy Questionnaire

Simply fill out the form below and you will be contacted promptly as soon as your information is processed.
The use of this form does not create an attorney-client relationship. Our law firm will not be representing you unless and until the terms of our representation are discussed and mutually agreed upon by you and our law firm, in writing.
* required fields

Full Name *
Address *
City *
State *
Zip *
Home Phone Number *
Work Phone Number
Email *
Social Security Number
Date of Birth
Gender	Male Female

OBLIGATIONS

Approx. total of all debt?
What type of bills do you have? (Check all that apply)
Credit Cards	Medical Bills
Judgments	Student Loans
Tax Debts	Government Fines
Personal Loans	Other

HOME

Approx. current value of home
Approx. current balance of home
Monthly Mortgage Payment
Are you up to date on mortgage payments?	Yes No
Are there any other mortgages on property?	Yes No
If yes, how much is owed?

VEHICLE 1

Year, make, & model
Date purchased
Approx. Value
Approx. balance owed
Monthly payment amount
Are payments current on this vehicle?	Yes No

VEHICLE 2

Year, make & model
Date purchased
Approx. Value
Approx. balance owed
Monthly payment amount
Are payments current on this vehicle?	Yes No

VEHICLE 3

Year, make, & model
Date purchased
Approx. Value
Approx. balance owed
Monthly payment amount
Are payments current on this vehicle?	Yes No

INCOME

Net monthly income from job or business
Net monthly income from spouse
Monthly disability amount
Monthly social security amount
Monthly pension amount
Monthly rental property amount
Monthly part-time job amount
Monthly child support amount
Monthly unemployment amount
Monthly workers compensation amount
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