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:
Amount #3:
Creditor #4:
Amount #4:
Creditor #5:
Amount #5:
Creditor #6:
Amount #6:
Authorized Surveillance Method: *
Do you have any student loans?: Yes No
If so, how much do you owe?:
grip-e-hp
