Name * Email * Phone * Do you intend to file a joint bankruptcy petition? If yes, include information for both yourself and your spouse below: Yes No Name(s), including middle initial Residence address, including county * How long have you been at this address? Phone (Work) Phone (Cell) Phone (Other) Have you used any other name(s) in the last six years? Yes No If yes, please list here Single Yes No Married Yes No Seperated Yes No Divorced Yes No If married, how long? If divorced, how long? Ages of minor children living with you Age and Amount of Child Support Paid: Is any child support past due? Yes No If child support is past due, what's the amount? Husbands Employment: How long at this job? Occupation Is income paid weekly, semi-monthly, monthly? Gross Net Wife's employment: How long at this job? Occupation Is income paid weekly, semi-monthly, monthly? Gross Net Income from other sources (second job, investments, social security, child support, worker's compensation, etc.) (state sources and amount): Do you owe any money to the Internal Revenue Service? Yes No If yes, for what year(s)? How much? Do you have any unpaid student loans? Yes No Amount Montly Expenses: Rent Monthly Expenses: Utilites Monthly Expenses: Phone Monthly Expenses: Cable Monthly Expenses: Trash Monthly Expenses: Real Estate Taxes Monthly Expenses: Home Maintenance Monthly Expenses: Life Insurance Monthly Expenses: Health Insurance Auto Insurance Monthly Expenses: Homeowner/Renters Insurance Monthly Expenses: House Payment Do you pay anyone spousal support (alimony) Yes No If yes, to whom and how much? Do you own or are you purchasing a home or other real property? Yes No Tax Assessed Value First Mortgage Loan Balance First Mortgage Loan Balance Loan Current? Amount Behind 2nd Mortgage Loan Balance Loan Current? Amount Behind 3rd Mortgage Loan Balance Loan current? Are you facing foreclosure? Yes No Foreclosure Date JanFebMar AprMayJun JulAugSep OctNovDec 12345678910111213141516171819202122232425262728293031 List any liens against your property List all vehicle loans (Estimated Loan Balance, Loan Current, and Amount Behind List all vehicles you own outright (no loan balance) Have you purchased any secured items (electronics, boats, jet ski, appliances, etc.) in the last two years on which you still owe money? Yes No Have you taken out a loan from a finance company, credit union, bank or any other place and secured the loan by household items or other type of secured collateral? Yes No Creditors' Names Estimate Balances: Medical Bills Estimate Balances: NSF Checks Estimate Balances: Credit Cards Estimate Balances: Misc. Bills When was the last time you used any of your credit cards? (approx. date) JanFebMar AprMayJun JulAugSep OctNovDec 12345678910111213141516171819202122232425262728293031 How much has total owed on cards gone up in the last 12 months? Have you had any new cards issued in the last 12 months? Do you anticipate receiving a tax refund? Yes No How much? List all judgments, lawsuits, liens, and garnishments against you. Special concerns Where did you hear about us? Copyright © 2007 by Law Office of Stephen H. Swift, P.C. All rights reserved.
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