Which of the following has happened to you RECENTLY?

(select all that apply)

 Creditor Harassment Disability or Illness Divorce Foreclosure Lawsuits of Judgments License Suspension Loss of Income Loss of Job Repossession None of the Above other

if other

Est. Total Debt

What kind of bills do you currently have?

 Auto Loans Child Support Credit Cards or Charge Cards Income Taxes Medical Bills Mortgage or Rent Payday Loans Personal Loans Other

if other

Est. total Monthly Bills

What kind of Assets do you CURRENTLY own?

Do you own a house?  yes no

If yes, are you bening in these payments?  yes no

Besides a house, do you own other real estate?  yes no

If yes, are you behind in these payments?  yes no

Do you own a car, truck or motorcycle?  yes no

If yes, are you behind in these payments?  yes no

Other Assets

If you own other assets not mentioned above, please list them in the box.

What are your CURRENT sources of income?

(select all that apply)

 Full-time Job Part-time Job(s) Social Security Pension or Retirement Child Support Payments Dividends or Interest I currently have no income Other

If Other

Est. Total Income

Contact Information

This information is required because we want your personal bankruptcy evaluation to be as accurate and thorough as possible.

First Name (required)

Last Name (required)

Email (required)

Address (required)

Phone (required)