Step 1 of 2 50% Start Your Path to Financial Freedom Today Schedule a Free Consultation Fill out the form below to get started and our team will contact you shortly.Have you made an appointment with our office yet?*Have you made an appointment with our office yet? (Required)Yes, I haveNo, I have notIf yes, on which day did you schedule your appointment? First Name* Last Name* Spouse's First Name Spouse's Last Name Street Address* City* Zip Code Phone*Work Phone*Email* EmployerEmployer, Position Spouse's Employer, Position QuestionnaireHow did you hear about us?How did you hear about us?RadioRecommendationInternet SearchYelpBar AssociationPre-Paid LegalReturning ClientHow long have your lived at your current address? What is your marital status?What is your marital status?MarriedDivorcedSingleSeparatedDo you have any children under the roof with you or are other wise dependents?Do you have any children under the roof with you or are other wise dependents?NoYesIf yes, how many and what are their ages? Do you own any real estate?*Do you own any real estate? (Required)NoYesDo you own any burial plots/plans or timeshares?Do you own any burial plots/plans or timeshares?NoYesDo you own any vehicles?Do you own any vehicles?NoYesDo you own or operate a business?Do you own or operate a business?NoYesDo you have any of the following property? Savings Account Stocks, Bounds, Investments Retirement Account Have you ever filed Bankruptcy before?Have you ever filed Bankruptcy before?NoYesAre you suing anybody or is anybody suing you?Are you suing anybody or is anybody suing you?NoYesCould you sue anybody?Could you sue anybody?NoYesIncome What is your approximate take home net income per month (not per pay period) after deductions for taxes, social security, and insurance? (Please include spouse's net income whether filing a case with you or not) Your First Job Net Income Per Month Your Spouse's First Job Net Income Per Month Your Second Job Net Income Per Month Your Spouse's Second Job Net Income Per Month Your Business Net Income Per Month Your Spouse's Business Net Income Per Month Your Food Stamp Amount Per Month Your Spouse's Food Stamp Amount Per Month Your Child Support Per Month Your Spouse's Child Support Per Month Your Retirement Net Income Per Month Your Spouse's Retirement Net Income Per Month Other Sources Your Other Sources of Net Income Per Month Your Spouse's Other Net Income Per Month Special Deductions Are there any special deductions out of your pay?Are there any special deductions out of your pay?NoYesYouYour Monthly Retirement Contribution? Your Monthly Repayments On Loans To Employer? Your Spouse Your Spouse's Monthly Retirement Contribution? Your Spouse's Monthly Repayments On Loans To Employer? Expenses What are your approximate expenses per month for the following items? Mortgage/Rent Second Mortgage Third Mortgage Maintenence Fee Out of Pocket Medical Expenses Electricity Laundry Water Haircuts Gas Cable CableTelephone Clothing Car Payment Car Insurance Child Support Food Child Care Charitable Giving Life Insurance Any Other Expenses (Ex: Diapers, Dog Food, Cigarettes) Mortgages and Other House Related Debts Mortgage 1: Name of Creditor Mortgage 1: Balance (Best Guess) Mortgage 1: Value of Real Estate Mortgage 2: Name of Creditor Mortgage 2: Balance (Best Guess) Mortgage 2: Value of Real Estate Mortgage 3: Name of Creditor Mortgage 3: Balance (Best Guess) Mortgage 3: Value of Real Estate If more, please add to general comments. Car Debts Car Debt 1: Name of Creditor Car Debt 1: Balance (Best Guess) Car Debt 1: Year and Type of Car Car Debt 2: Name of Creditor Car Debt 2: Balance (Best Guess) Car Debt 2: Year and Type of Car Car Debt 3: Name of Creditor Car Debt 3: Balance (Best Guess) Car Debt 3: Year and Type of Car If more, please add to general comments. Credit Cards Credit Card 1: Name of Creditor Credit Card 1: Balance (Best Guess) Credit Card 2: Name of Creditor Credit Card 2: Balance (Best Guess) Credit Card 3: Name of Creditor Credit Card 3: Balance (Best Guess) Credit Card 4: Name of Creditor Credit Card 4: Balance (Best Guess) Credit Card 5: Name of Creditor Credit Card 5: Balance (Best Guess) Credit Card 6: Name of Creditor Credit Card 6: Balance (Best Guess) If more, please add to general comments. Signature Loans With CollateralSignature Loan with Collateral 1: Name of Creditor Signature Loan with Collateral 1: Balance (Best Guess) Signature Loan with Collateral 2: Name of Creditor Signature Loan with Collateral 2: Balance (Best Guess) Signature Loan with Collateral 3: Name of Creditor Signature Loan with Collateral 3: Balance (Best Guess) HiddenUntitled If more, please add to general comments. Signature Loans Without Collateral Signature Loan without Collateral 1: Name of Creditor Signature Loan with Collateral 1: Balance (Best Guess) Signature Loan without Collateral 2: Name of Creditor Signature Loan with Collateral 2: Balance (Best Guess) Signature Loan without Collateral 3: Name of Creditor Signature Loan with Collateral 3: Balance (Best Guess) If more, please add to general comments. Medical Bills Medical Bill 1: Name of Creditor Medical Bill 1: Balance (Best Guess) Medical Bill 2: Name of Creditor Medical Bill 2: Balance (Best Guess) Medical Bill 3: Name of Creditor Medical Bill 3: Balance (Best Guess) If more, please add to general comments. Student Loans Student Loan 1: Name of Creditor Student Loan 1: Balance (Best Guess) Student Loan 2: Name of Creditor Student Loan 2: Balance (Best Guess) Student Loan 3: Name of Creditor Student Loan 3: Balance (Best Guess) If more, please add to general comments. Loans to Family and Friends Loan to Family / Friend 1: Name of Creditor Loan to Family / Friend 1: Balance (Best Guess) Loan to Family / Friend 2: Name of Creditor Loan to Family / Friend 2: Balance (Best Guess) Loan to Family / Friend 3: Name of Creditor Loan to Family / Friend 3: Balance (Best Guess) If more, please add to general comments. OthersName of Other Creditor #1 Other Balance 1 (Best Guess) Name of Other Creditor #2 Other Balance 2 (Best Guess) Name of Other Creditor #3 Other Balance 3 (Best Guess) If more, please add to general comments. Back Tax Debt Back Tax Debt 1: Name of Creditor Back Tax Debt 1: Type of Tax Back Tax Debt 1: Year Back Tax Debt 1: Balance (Best Guess) Back Tax Debt 2: Name of Creditor Back Tax Debt 2: Type of Tax Back Tax Debt 2: Year Back Tax Debt 2: Balance (Best Guess) Back Tax Debt 3: Name of Creditor Back Tax Debt 3: Type of Tax Back Tax Debt 3: Year Back Tax Debt 3: Balance (Best Guess) If more, please add to general comments. General CommentsMessage 45348
