Personal Info

Marital Status:
Choose One Single Married Divorced Separated

If married, what is spouse's name

If married, do you plan to file bankruptcy as an individual, or jointly with your spouse?

Choose One (if married) Individual Jointly Not Sure

 How many people are in your household that you must support? (include yourself & your spouse):

Where did you hear about us?

Qwestdex Referral by Mailing Yellow Book TV Directory Westword Search Engine Other Choose One   

What Kind of Debts do you have?
(list approximate amount)

Other

How much debt do you have not counting vehicles or mortgages?  

$

How many creditors do you believe that you have?

If you have credit card debt, when was the last time you charged?

What is your monthly household net income (after taxes, take home income)?

(Include spouse's income even if you intend to file individually)

You    $       Spouse    $

Vehicles

Do you own any vehicles?     YES         NO

If you answered "YES" above complete the following information:

Vehicle 1

What are your intentions with this vehicle? Choose One Keep Vehicle Surrender Vehicle

Vehicle 2

What are your intentions with this vehicle? Choose One Keep Vehicle Surrender Vehicle

Vehicle 3

What are your intentions with this vehicle? Choose One Keep Vehicle Surrender Vehicle

Real Estate

Do you own any real estate?     YES         NO

If you answered "YES" above complete the following information:

What are your intentions with this real estate? Choose One Keep Home Surrender Home

Have you refinanced in the last two years?
YES        NO

How many mortgages do you have on your property?

How much is owed on each mortgage?    

What do you think you could sell the home for if you wanted to?  

$

Have you sold or transferred any real estate in the last four years?

YES NO

Other Assets

Describe any other assets you own that have significant value

Description

Approx. Value $

Description

Approx. Value $

Description

Approx. Value $

Taxes

What did you show for taxable income on your most recent tax return (AGI)?

$

Do you owe the IRS or state for back taxes?   

   YES         NO

Are there any years for which you have not filed state or federal income tax returns?    

YES         NO     

If yes, what years?

Did you get a tax refund last year?    

YES         NO     

If yes, how much?   $

Additional Information

Have you ever filed bankruptcy before?
YES         NO   

If yes, what year?


what chapter
Chapter 7 Chapter 13

In the last two years have you given or paid more than $500 to any friend or relative?
YES         NO

Does anyone owe you any money?
YES         NO

Amount:
$

Have creditors been calling you at home or work?
(Home)    YES      NO
(Work)    YES    NO

Have you been served with a summons in the last year?    
YES         NO

Have you been involved in a law suit in the last year? YES       NO

If you answered yes above, please give brief description of the law suit:

Are your wages being garnished?
YES         NO

Are you behind on your home and/or car payment?
YES         NO

Will you have trouble obtaining the address of any of your creditors?
YES         NO

What do you pay monthly for the following (approximately)?

Is there any additional information that may be relevant to your case?

Are there any questions that you need an answer for right now?

Do you own a business?
YES       NO

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