| Full Name |
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| Address |
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| Phone |
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| Email Address |
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| Best time to contact you? |
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What type of bills do you have? (Check all that apply) |
Credit Cards Medical Bills Judgments Student Loans Tax Debts Government Fines Personal Loans
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| Number of bills |
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| 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
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| 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
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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) |
$ |
| |
|