*Name:
*Address:
*City:
*State: Choose One AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY
*Zip:
*E-mail address:
*Home Phone:
Business Phone:
Cellular or Pager:
Facsimile:
Do you intend to file a joint bankruptcy petition? Yes No
If yes, include information for both yourself and your spouse below.
Name(s), including middle initial.
*Residence address, including county.
How long have you been at this address?
Other telephone number(s)
Work
Cell
Other
Have you used any other name(s) in the last six years? Yes No
If yes, please list here
Single Separated Married Divorced
If married, how long? >
If divorced, how long?
Ages of minor children living with you
Ages, and amount of child support paid:
Is any child support past due? Yes No
Amount $
Husband's employment:
How long at this job?
Occupation
Income paid weekly semi-monthly monthly other
Gross
Net
Wife's employment (name and addr.):
Income from other sources (second job, investments, social security, child support, worker's compensation, etc. (state source and amount):
Do you owe any money to the Internal Revenue Service? Yes No
If yes, for what year(s)?
How much? $
Do you have any unpaid student loans? Yes No
Monthly Expenses
Do you pay anyone spousal support (alimony) Yes No
If yes, to whom and how much?
Do you own or are you purchasing a home or other real property? Yes No
Tax assessed value $
First Mortgage Loan Balance $
Loan Current?
Amount Behind $
2nd Mortgage Loan Balance $
3rd Mortgage Loan Balance $
Are you facing foreclosure? Yes No
Foreclosure Date
List any liens against your property
List all vehicle loans (car, truck, motorcycles; identify vehicle type)
List all vehicles you own outright (no loan balance)
Have you purchased any secured items (electronics, boats, jet ski, appliances, etc.) in the last two years on which you still owe money? Yes No
Have you taken out a loan from a finance company, credit union, bank or any other place and secured the loan by household items or other type of secured collateral? Yes No
Creditors' Names
Estimate balances owed on all other types of debt listed below
When was the last time you used any of your credit cards? (approx. date)
How much has total owed on cards gone up in the last 12 months?
Have you had any new cards issued in the last 12 months?
Do you anticipate receiving a tax refund? Yes No
Are you eligible for the Earned Income Credit? Yes No
List all judgments, lawsuits, liens and garnishments against you.
Special concerns
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