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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.

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Full Name *
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Home Phone Number *
Work Phone Number
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Social Security Number
Date of Birth
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OBLIGATIONS

Approx. total of all debt?

What type of bills do you have? (Check all that apply)
Credit CardsMedical Bills
JudgmentsStudent Loans
Tax DebtsGovernment Fines
Personal LoansOther
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
Best time to contact you
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