Name

Address

Telephone

E-Mail

How did you find out about our office?

reputation

referral

Yellow book
Internet Search

Are you employed?

Yes No

  Yearly Gross Household Income

   Number living in household

  Marital Status

  If married are you filing a joint case?

  Have you previously filed a bankruptcy?

ASSETS:

Automobile # 1

 Year

Make

Model

 Market Value

 Pay off balance

Automobile # 2

 Year

Make

Model

Market Value

Pay off balance  

Other Vehicles

 Year 

Make    

Model

Market Value

Pay Off Balance

Real Property

 Market Value of Residential Real Property

 Pay off balance on mortgages

 Total arrears including property taxes

Rental and Investment Property

 Market Value of all other real property

 Pay off balance on mortgages

 Total arrears including property taxes

Personal Property

 Total value of electronics, sporting goods, hobby equipment, jewelry, tools, collections, household appliances except refrigerator and stove.

 Total value of household furniture, clothing, books including refrigerator and stove.

Bank Accounts

  Total cash value of accounts except pension.

LIABILITIES

  Total Credit Card, Medical and unsecured signature loans, and student loans.

  Total signature loans for which you pledged personal property collateral. (Do not include home equity or car loans)

  Total current value of collateral pledged

Income Tax Debt Federal:

Amount past due since April 15 2005   $

Amount past due before April 15, 2005 $

Income Tax Debt State:

Amount past due since April 15, 2005  $

Amount past due before April 15, 2005 $

Lawsuits Pending; (enter attorneys name and creditor):

Judgments: (enter attorneys name, creditor, court, and date of judgment)

Wage Garnishments: (enter attorneys name and creditor)

Pending repossessions, Sheriff's levy and sale, foreclosure, attachments on bank accounts:

Criminal Actions Pending: