| Your Name | |
| Social Security # | |
| D.O.B. | |
| Spouse's Name | |
| Spouse's S.S. # | |
| D.O.B. | |
| Daytime Phone # | |
| Evening Phone# | |
| Prefer contact during: | Daytime Evening |
| Email address: | |
| | |
INCOME |
| 1.Are you married? | Y or N |
| 2.How do you plan to file your bankruptcy? | Single or Joint? |
| 3. Do you have Dependant Children living with you? | Y or N |
| If yes, how many? | |
| 4. Do You work? | Y or No |
| If so, how much do you earn annually? | $ |
| Are you paid | Hourly or Salary ? |
| | $/HR |
| | $ Salary/ Week Month Year |
| 5. Are you wages being garnished? | Yes No |
| If so, how much? | $ WeeklyBi-weekly |
| 6. Does your spouse work? | Y or N |
| If so, how much do they earn annually? |
$ |
| 7. How is spouse paid? | Hourly or Salary ? |
| | $/HR |
| | $ Salary/ Week Month Year |
8. Are spouse's wages currently being garnished? | Yes No |
| If so, how much? | $ WEEKLY BI-WEEKLY |
| TOTAL YEARLY HOUSEHOLD INCOME | $ |
| 9. Do you receive Child Support? | Y or N |
| a. If so, how much per month? | $ |
| | |
MONTHLY LIVING EXPENSES |
| 10. Do you currently have a mortgage? | Y or N (If NO, skip to # 12) |
| a. If so, what is your monthly payment? | $ |
| b. Are you behind in mortgage payments? | Y or N |
| c. If yes, how many months? | |
| d. What is your total debt on the mortgage? $ | |
e. What is the State Equalized Value of Your home? | $
(See recent property tax statement for this) |
11. Do you have a second mortgage or
Home Equity Loan ? |
Y or N |
| a. Monthly payment on the second mortgage? | $ |
| b. Estimate the selling value of your home? | $ |
c. Amount owed on second mortgage or
Home Equity loan? |
$ |
| | |
| 12. Do you own any cottages, rental properties or vacation homes? |
Y or N |
| a. If so, how much do you pay monthly? | $ |
| b. What is the total debt on the property? | $ |
| c. Amount of equity in 2nd Property | $ |
13. Are you behind on property taxes
on any property? |
Y or N |
| If so, detail for each property: |
| Property 1: | $ |
| Address: | |
| Property 2: | $ |
| Address: | |
| Property 3: | $ |
| Address: | |
| | |
| 14. Do you Rent? | Y or N |
| a. If so, how much is your monthly payment? | $ |
| b. Are you behind on your Rent payment? | Y or N |
| c. How many months are you behind? | |
| | |
| 15. Do you pay child support? | Y or N |
| . If so, how much per week? | $ |
| | |
16. Do you make monthly payments on an automobile OR any Motor vehicle
(boat, jet ski, motorcycle,snowmobile, etc.) | Y or N |
| a. If so, do you | OWN LEASE ? Both(different vehicles) |
| b. What are your total monthly vehicle payment? |
$ |
| c. How many months behind are you (If any) | |
| d. How much is the total insurance per month? | $ |
| 17. Do you make monthly student loan payments? |
Y or N |
| a. If so, how much per month? | $ |
| b. Total Student Loan Debt | $ |
18. If you have a retirement fund, how much is it worth? |
$ |
| a. If you have borrowed from it, how much | $ |
| b. Date you borrowed the money: | |
| | |
19. How much do you spend
per month on Food? |
$ |
| 20. How much do you spend per month on Clothing? |
$ |
21. Monthly cost of Medical Insurance
and Medical Bills? |
$ |
| 22. Monthly cost of child(ren) schooling/Day Care? | $ |
| | |
| 23. How much do you spend per month on the following Utilities? |
| a. Phone Bill (include cellphone & "land line") | $ |
| b. Electric/Gas | $ |
| c. Cable/ Internet/Dish | $ |
| d. Other (laundry, dry cleaning) | $ |
| 24. If you smoke, monthly cost? | $ |
| 25. If you have pets, monthly expense? | $ |
| | |
DEBTS |
Please list Total Amounts Owed for Each Debt Type:(Use "Ballpark" amounts for each debt) |
| 26. Credit Cards (Total Amount of all Cards) | $ |
| 27. Unpaid Medical Bills | $ |
| 28. Personal Loans | $ |
29. Vehicle(car,motorcyle,snowmobile/ATV,etc.) Repossessions |
|
