| Full Name |
|
| Address |
|
| Phone |
|
| Email Address |
|
| Best time to contact you? |
|
What type of bills do you have?
(Check all that apply) |
Credit Cards
Medical Bills
Judgments
Student Loans
Tax Debts
Government Fines
Personal Loans
|
| Number of bills |
|
| Amount Owed: |
Under $5,000
$5,000 - $10,000
$10,000 - $15,000
$15,000 - $20,000
$20,000 - $30,000
$30,000 - $40,000
$40,000 - $50,000
Over $50,000
|
| Approximate value of home: |
$ |
| Approximate balance on mortgage: |
$ |
| Monthly mortgage payment: |
$ |
| Are you up to date on your mortage payments? |
Yes
No |
| Are there any other mortgages on this property? |
Yes
No |
Vehicle 1
Year/Make/Model: |
|
| Approximate Value: |
$ |
| Approximate Balance: |
$ |
| Monthly Payment: |
$ |
| Are your payments up to date? |
Yes
No |
Vehicle 2
Year/Make/Model: |
|
| Approximate Value: |
$ |
| Approximate Balance: |
$ |
| Monthly Payment: |
$ |
| Are your payments up to date? |
Yes
No |
| Enter any other property of significant value.(For example, if you own a boat, list it here.) |
|
You
Are you employed? |
Yes
No
|
| How often do you get paid? |
every week
every 2 weeks
twice a month
monthly
|
Net Pay:
(after taxes, medical adn other deductions) |
$ |
What other types of income do you have?
(Check all that apply) |
Disability
Social Security
Pension
Rental Property
Part-time Job
Child Support
Unemployment
Worker's Compensation
|
Spouse (optional)
How often do you get paid? |
every week
every 2 weeks
twice a month
monthly
|
Net Pay:
(after taxes, medical adn other deductions) |
$ |
| |
|