Questionnaire for New Debt Relief Clients

What to bring to your appointment.

Drivers License or State ID
Recent Credit Report (if available)
Bills/Collection letters
Vehicles / Car Loan Information
Real Estate and/or Mortgage Information
Proof of Insurance on your House
Tax Returns (2 years if available)
Recent Paystubs
Our Questionaire

Complete the Questionnaire to the best of your ability. This form will help prepare you for the initial consultation, and can help the attorney best determine the most appropriate form of debt relief. You may either complete the form online below or download it and bring it with you to your appointment.

Client Confidential Worksheet

First Name

Last Name

Marital Status

Address

Address Line 1

Address Line 2

City

State

Country

Zip Code

Are you filing jointly with your spouse or individually?

Spouse Name

Marital Status

Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

Prior Bankruptcy Filed? If Yes: Where

When

Judge’s Name

Status of Case

LIST OF CREDITORS

Please list creditors below. Any additional creditors, please list on back.

Creditor

Account Number

Balance

Creditor

Account Number

Balance

Creditor

Account Number

Balance

Creditor

Account Number

Balance

Creditor

Account Number

Balance

PROPERTY INFORMATION

Real Property: (i.e.: home or land)

1. Location of property: (Full Address) Value: $

2. Cash on hand: $

3. Checking Account: $

Bank

Acct.No.

4. Savings Account: $

Bank

Acct.No.

5. Security deposits

6, Home Furnishings: Make a separate itemized list of all home furnishings broken down by room. (I.e.: Bedroom 1:bed - $25, dresser - $50, TV - $10)

7. Furs or Jewelry

Value

8. Firearms, sports or other hobby equipment:

Value

9. Interest in insurance policies, annuities, IRA, ERISA, 401k etc.

Value

10. Stock interest in an incorporat e d or un in corporated business.

Value

11. Interest in partnerships or joint ventures

12. Alimony, maintenance, support payments you are entitled to

13. Any tax refund s you are expecting $

14. Auto, truck, trailer, other v e hicle : Year

Make

Model

Value

15. Auto, truck, trailer, other v e hicle : Year

Make

Model

Value

16. Boats, Motors, Accessories

Value

EMPLOYER INFORMATION

Your Employer

Name

Occupation

Address (Full)

How often paid: (Circle one ) Weekly Bi ‐ weekly Twice a month Monthly Gross pay:

Spouse Employer

Name

Occupation

Address (Full)

Any other source of income not listed

ESTIMATED MONTHLY LIVING EXPENSES

Rent or Mortgage payment $

Property Insurance $

Electric $

Water / Sewer $

Phone $

Garbage $

Cable $

Food $

Car Payment 1 $

Car Payment 2 $

Car Insurance $

Health Insurance $

Life Insurance $

Medical Insurance $

Cell Phone $

Other $

Nature of Payment

We put in standard amounts the court allows for transportation, home maintenance, recreation and clothing. Please fill out to the best of your ability. Thank you.

New Clients