Identity
Name:
Spouse Name:
Street Address:
City:
State:
Alabama
Alaska
American Samoa
Arizona
Arkansas
Armed Forces - Americas
Armed Forces - Europe/Africa/Canada
Armed Forces - Pacific
California
Colorado
Connecticut
Delaware
District of Columbia
Federated States of Micronesia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Marshall Islands
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Palau
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip Code:
Phone Number:
Email Address:
Have you filed for Bankruptcy before:
Yes
No
Please list when and where:
Do you have any children under the age of 18:
Yes
No
Please list their age and gender:
Do you have any children in college:
Yes
No
Please state how many:
Income
Please provide a recent paycheck stub for each debtor if you can, or give me an estimate for all categories that apply.
Hourly Pay Rate:
Salary:
Average gross income per month:
Income from last year's tax returns:
Recent Paycheck Stub:
Accepted Formats :
Excel Documents, Images, PDFs, Word Documents
Spouse Hourly Pay Rate:
Spouse Salary:
Spouse Average gross income per month:
Spouse income from last year's tax returns:
Spouse Recent Paycheck Stub:
Accepted Formats :
Excel Documents, Images, PDFs, Word Documents
Assets
Do you own a home?:
Yes
No
Date of Home Purchase:
Value of home:
Mortgage amount:
Do you own other real estate?:
Yes
No
Real Estate Street Address:
Real Estate City:
Real Estate State:
Alabama
Alaska
American Samoa
Arizona
Arkansas
Armed Forces - Americas
Armed Forces - Europe/Africa/Canada
Armed Forces - Pacific
California
Colorado
Connecticut
Delaware
District of Columbia
Federated States of Micronesia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Marshall Islands
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Palau
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Real Estate Zip Code:
Date of Real Estate Purchase:
Value of property:
Mortgage amount:
Do you own a vehicle?:
Yes
No
Year:
Make:
Model:
Value:
Amount owing:
Do you own another vehicle?:
Yes
No
Vehicle 2 Year:
Vehicle 2 Make:
Vehicle 2 Model:
Vehicle 2 Value:
Vehicle 2 Amount owing:
Do you own another vehicle?:
Yes
No
Vehicle 3 Year:
Vehicle 3 Make:
Vehicle 3 Model:
Vehicle 3 Value:
Vehicle 3 Amount owing:
Business Assets
Are you self employed or the owner of a corporation or LLC?:
Yes
No
What does your business do?:
Number of Employees:
Business Street Address:
Business City:
Business State:
Alabama
Alaska
American Samoa
Arizona
Arkansas
Armed Forces - Americas
Armed Forces - Europe/Africa/Canada
Armed Forces - Pacific
California
Colorado
Connecticut
Delaware
District of Columbia
Federated States of Micronesia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Marshall Islands
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Palau
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Business Zip Code:
Business Real Estate Value:
Business Mortgage amount:
Vehicles, Equipment, and Tools:
Value of each:
Creditors
Please list your creditors and amounts owing. I don't need addresses or exact amount, an estimate is fine and I don't need a complete list.
Creditor #1:
Amount #1:
Creditor #2:
Amount #2:
Creditor #3:
Authorized Business Phone Number:
*
Amount #3:
Creditor #4:
Amount #4:
Creditor #5:
Amount #5:
Creditor #6:
Amount #6:
Do you have any student loans?:
Yes
No
If so, how much do you owe?:
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