Name


Address


City


State


E-mail Address


Phone Number


Pager or Mobile/Cell Phone Number


What is the best time to contact you?


Who were you referred by, or how did you find us?


Are you married:

No, I'm Single. Yes, I'm Married. I'm legally separated or going through a divorce.

Are you or your spouse employed?

Yes. No.

What is your monthly income after taxes?


Do you want to file bankruptcy?

No, I need other legal services. Yes, I want a chapter 7 bankruptcy. Yes, I want a chapter 13 bankruptcy. Yes, But I don't know which chapter of bankruptcy.

If you do NOT plan to file bankruptcy,
please skip down to the comment area now.

Will just you, or you and your spouse, be filing?


Have you ever filed bankruptcy before?

Yes, I have filed bankruptcy before. No, I've never filed bankruptcy.

Do you own, or are you buying, a home?

Yes. No.

If you own, are you current on your house payments?

Yes, no more then 30 days late. No, but not more than three months late. No, the house is near or in foreclosure.

Would you like to keep your home?

Yes. No.

Do you own, or are you buying, a vehicle?

Yes. No.

If you own, are you current on your vehicle payments?

Yes, no more then 30 days late. No, but not more than three months late. No, the vehicle has been or is about to be repossessed.

Would you like to keep your vehicle?

Yes. No.

Briefly describe your debts.
(medical, credit card, child support, taxes, etc)


Any other comments: