Questionnaire
Today’s date:_______________ How did you hear about us?___________________________
Your Name (as it appears on Soc. Sec. Card):________________________________________ Date of Birth:______________
Maiden name/former names:____________________________________________
Social Security Number: _________________________________ Marital status:________________
Your address:___________________________________________ Apt. #:_____ Rent Own
City: ______________________________ State: _______________ Zip: _______________ County:___________
Home phone: ___________________________________ Cell: _________________________________
E-Mail address:_________________________________________
Spouse's Name: ________________________________________ Date of birth:_____________________
Spouse's maiden/former name:_____________________________________________
Spouse's social security number: ____________________________________
Spouse's home address and home phone (if different from yours):_____________________________________________________
How long have you lived at your home address:___________________________________________
If less than 2 years, please list previous addresses, beginning with the most recent:
Income Information
Yourself Spouse
Job title/occupation: ___________________ ____________________
Employer: ___________________ ____________________
How long there: ___________________ ____________________
Payroll address: ___________________ ____________________
City, ST Zip ___________________ ____________________
Payroll office phone #: ___________________ ____________________
Date next paycheck
expected ___________________ ____________________
Children & Step-children
Name Age Relationship Does child live with you? Child support $ paid/received
Expected changes in income:
Describe when & why:______________________________________________________________________
Income & Expenses
Yourself Spouse
How often are
you paid? ______________ ______________
GROSS PAY
PER PAYCHECK _____________ ______________
Payroll deductions:
- FICA (Soc. Sec.) ______________ ______________
- Federal tax ______________ ______________
- Medicare ______________ ______________
- State tax ______________ ______________
- Insurance ______________ ______________
- Savings/bonds ______________ ______________
- Uniform/union ______________ ______________
- Pension/401(k) ______________ ______________
- 401(k) loan ______________ ______________
- Credit Union savings ______________ ______________
- Credit Union loan ______________ ______________
- Child support ______________ ______________
- Garnishments ______________ ______________
TAKE HOME PAY
PER PAYCHECK: ______________ ______________
Other sources of income (please describe)
___________________________________________________________________
Household Expenses
Household expenses Notes
Rent/mortgage
payments _______________________ _________________________
Electric bill _______________________ _________________________
Gas bill _______________________ _________________________
Water/sewer _______________________ _________________________
Telephone _______________________ _________________________
Cable TV _______________________ _________________________
Home maintenance _______________________ _________________________
Food _______________________ _________________________
Clothing _______________________ _________________________
Laundry/dry cleaning _______________________ _________________________
Medical/dental _______________________ _________________________
Gasoline/bus fare _______________________ _________________________
Entertainment _______________________ _________________________
Charity/church _______________________ _________________________
Homeowners/renter's
insurance ________________________ _________________________
Life insurance ________________________ _________________________
Health insurance
(not deducted from pay) _________________________ _________________________
Auto insurance _________________________ _________________________
Non-payroll taxes _________________________ _________________________
Car/truck payment _________________________ _________________________
Alimony _________________________ _________________________
Child support paid out _________________________ _________________________
Child care expenses _________________________ _________________________
Emergency matters . . .
Are you currently facing a mortgage foreclosure:_____________
If so, how do you know:______________________________________________
For what month is the foreclosure scheduled:_____________________________
Are you currently facing a vehicle repossession:______________
If so, who is the finance company?_______________________________________
How far are you behind?_______________________________________________
Yearly income
Year Gross income/year Where employed? Spouse’s gross income/year Where was spouse employed?
Your Year to date
Spouse’s Year to date
Tax returns (last 2 years)
Year Tax returns filed? If not, why not Spouse filed tax returns? If not, why not?
Has the IRS, this State or any other taxing entity ever advised you that a tax lien has been filed against you?
_________________________________________________________
Within the last ten (10) years, have you or your spouse not filed tax returns? If so, please describe:
_________________________________________________________
Has a lawsuit ever been filed against you - has a sheriff's deputy ever served a summons upon you?
______________________________________________________________
Lawsuit filed against you by: Reason for lawsuit & date lawsuit served on you County where filed Case number Status
now
Have your wages ever been garnished? .(if needed, list on separate sheet of paper & attach)
Who is garnishing When did garnishment begin How much $ taken to date Is garnishment on-going Who is plaintiff’s
lawyer?
Have you ever lost a house to a mortgage foreclosure?
Mortgage company/lender Foreclosing law firm When was house sold Address of lost property Status now
Please identify any real estate that is in your name.
Property address Date purchased Purchase price Value now Total debt owed on property
Please identify any cars or trucks you own.(if needed, list on separate sheet of paper & attach)
Year/make/model of vehicle & mileage Date purchased In whose name Value now Total debt owed on property
Are you currently involved in a car accident claim, workers’ compensation claim or any other claim that may result in money damages
payable to you? Please describe:____________________________________________________
Please identify any bank accounts you own. .(if needed, list on separate sheet of paper & attach)
Name of bank Checking/savings? In whose name Current balance Any other loans or credit cards with this lender?
Please identify any pension, 401(k)or profit-sharing programs in which you participate
Name of financial institution Type of plan In whose name Are you still contributing? Current balance Any loans
against this plan?
Other assets not yet described (i.e. boats, stocks/bonds, antiques, musical instruments, valuable collections, insurance policies with
cash value, guns, sporting equipment, jewelry, etc.) .(if needed, list on separate sheet of paper & attach)
Asset description Current value Who owns this asset? Has asset been pledged as collateral for a loan?
Have you ever lost a car to repossession?.(if needed, list on separate sheet of paper & attach)
Car finance company When was vehicle seized Vehicle make/model Have you received notice that you still owe money on
vehicle?
Recent activity .(if needed, list on separate sheet of paper & attach)
During the last 60 days, have you done any of the following Yes/No Name of lender/transferee Amount borrowed w/in last
60 days
Used credit cards
Taken cash advances
Taken out any new loans
Gave away or sold any property worth more than $600
Have you ever filed a Chapter 7 or a Chapter 13 bankruptcy before?
Type of bankruptcy (Ch. 7 or Ch. 13 Date filed Was case completed or dismissed? When was case closed by Court
Case number Former BK lawyer
DISCLOSURE CERTIFICATE
I, the undersigned, hereby attest and affirm that all debts, whether joint debts, co-signed debts, claims or lawsuits for collection of
debts, whether disputed or not, have been listed on my questionnaire.
I acknowledge that my bankruptcy preparer relies on the information provided in this questionnaire in order to assist me, and that it is
my responsibility to provide full, complete and accurate financial disclosure. I further agree to update my bankruptcy preparer with
regard to any incomplete information contained herein.
I further acknowledge that in the event a creditor is omitted from any bankruptcy petition filed as a result of an omission on this
questionnaire, I will not have the protection of the Bankruptcy Court from actions by that creditor.
Date_________________ Signature____________________________________
Date_________________ Signature____________________________________
Taxes Due
Internal Revenue Service Account Number:____________________________________
Address:_______________________________________________________________________________
For tax year:________________ Total taxes due to IRS for tax year:_________________
Return filed?________ In whose name:_____________________ Installment agreement filed?___________
Dept. of Revenue Account Number:_____________________________________
Address:_______________________________________________________________________________
For tax year:________________ Total taxes due to IRS for tax year:_________________
Return filed?________ In whose name:_____________________ Installment agreement filed?___________
Other taxes:__________________________________Account number:_____________________
Address:_________________________________________________________________________________
What type of tax is this?____________Tax year:_______________Taxes due (total)____________________
In whose name:___________________________ Return filed?____________________
Other taxes:______________________________________Account number:_____________________
Address:_________________________________________________________________________________
What type of tax is this?____________Tax year:_______________Taxes due (total)____________________
In whose name:___________________________ Return filed?_____________________
Mortgages & Real Estate .(if needed, list on separate sheet of paper & attach)
First Mortgage:__________________________________ Acct. #:_______________________________
Address:______________________________ Phone #:_______________ Total loan payoff: $________
Does payment include taxes & insurance?
City:_______________________ ST:_____ Zip:____________ Monthly payment:_________
How many months behind are you?_______________ What happened:____________________
When did you take mortgage out:_________________ When did you buy property:____________
Address of property:________________________________ Is this your residence?_________
In whose name is loan?_______________ Co-signers?____________ Who is this person:______________
How much is property worth in a quick sale?________________ Has foreclosure started?________________
Who is foreclosure attorney?___________________________________________________________
Second Mortgage:_______________________________ Acct. #:_____________________________
Address:____________________________ Phone #:_________________ Total loan payoff: $________
City:_______________________ ST:_____ Zip:____________ Monthly payment:________________
How many months behind are you?_______________ What happened:___________________________
When did you take mortgage out:_________________ When did you buy property:______________
Address of property:________________________________ Is this your residence?___________________
In whose name is loan?_____________ Co-signers?______________ Who is this person:_____________
How much is property worth in a quick sale?________________ Has foreclosure started?________________
Who is foreclosure attorney?_________________________________________________________________
Home Improvement loan:_____________________ Acct. #:_____________________________
Address:____________________________ Phone #:_________________ Total loan payoff: $________
City:_______________________ ST:_____ Zip:____________ Monthly payment:________________
When did you take loan out:_________________ How did you use money?:______________
Cars & Trucks.(if needed, list on separate sheet of paper & attach)
Vehicle 1 – (year, make & model)___________________________________________________________
Finance/loan company:___________________________________ Acct #:_________________________
Address:_______________________________________________ Monthly payment: $______________
City:___________________ ST: __________ Zip:_____________ Payoff of loan: $_______________
How many months behind are you?_______________ What happened:___________________________
In whose name:___________________ Co-signers:____________________________________________
Is this a lease or a purchase:________________________ When was vehicle bought:_________________
Vehicle insurance company:__________________________ Ins. Expiration:_______________________
Vehicle 2 – (year, make & model)__________________________________________________________
Finance/loan company:___________________________________ Acct #:________________________
Address:______________________________________________ Monthly payment: $______________
City:_________________ ST: __________ Zip:_____________ Payoff of loan: $_________________
How many months behind are you?_______________ What happened:___________________________
In whose name:___________________ Co-signers:___________________________________________
Is this a lease or a purchase:________________________ When was vehicle bought:_________________
Vehicle insurance company:__________________________ Ins. Expiration:_______________________
Vehicle 3 – (year, make & model)__________________________________________________________
Finance/loan company:_________________________________ Acct #:__________________________
Address:_______________________________________________ Monthly payment: $______________
City:_________________ ST: __________ Zip:_____________ Payoff of loan: $________________
How far behind are you:_________In whose name:___________________ Co-signers:_______________
Is this a lease or a purchase:________________________ When was vehicle bought:_________________
Furniture Loans .(if needed, list on separate sheet of paper & attach)
Furniture 1 (describe furniture):_________________________________________________________
Finance/loan company:________________________________ Acct #:__________________________
Address:____________________________________________ Monthly payment: $______________
City:_________________ ST: __________ Zip:____________ Total loan payoff: $_______________
In whose name:___________________ Co-signers:________________________________________
When was merchandise purchased:______________________ Do you still have it?________________
Do you want to surrender furniture and reduce or eliminate debt?______________________________
Furniture 2 (describe furniture):_________________________________________________________
Finance/loan company:________________________________ Acct #:__________________________
Address:____________________________________________ Monthly payment: $______________
City:_________________ ST: __________ Zip:____________ Total loan payoff: $_______________
In whose name:___________________ Co-signers:________________________________________
When was merchandise purchased:______________________ Do you still have it?________________
Do you want to surrender furniture and reduce or eliminate debt?______________________________
Furniture 3 (describe furniture):_________________________________________________________
Finance/loan company:________________________________ Acct #:__________________________
Address:____________________________________________ Monthly payment: $______________
City:_________________ ST: __________ Zip:____________ Total loan payoff: $_______________
In whose name:___________________ Co-signers:________________________________________
When was merchandise purchased:______________________ Do you still have it?________________
Do you want to surrender furniture and reduce or eliminate debt?______________________________
Finance Companies and Loan Companies .(if needed, list on separate sheet of paper & attach)
Finance Company Loan 1 Did you pledge household goods (describe)______________________
Finance/loan company:_____________________________ Acct #:__________________________
Address:_________________________________________ Monthly payment: $______________
City:_________________ ST: ______ Zip:___________ Total loan payoff: $_______________
In whose name:___________________ Co-signers:_____________________________________
When did you take out loan:______________________ If you pledged household goods, do you
want to surrender collateral and reduce or eliminate debt?______________________________
Finance Company Loan 2 Did you pledge household goods (describe)______________________
Finance/loan company:_____________________________ Acct #:__________________________
Address:_________________________________________ Monthly payment: $______________
City:_________________ ST: ______ Zip:___________ Total loan payoff: $_______________
In whose name:___________________ Co-signers:_____________________________________
When did you take out loan:______________________ If you pledged household goods, do you
want to surrender collateral and reduce or eliminate debt?______________________________
Finance Company Loan 3 Did you pledge household goods (describe)______________________
Finance/loan company:_____________________________ Acct #:__________________________
Address:_________________________________________ Monthly payment: $______________
City:_________________ ST: ______ Zip:___________ Total loan payoff: $_______________
In whose name:___________________ Co-signers:_____________________________________
When did you take out loan:______________________ If you pledged household goods, do you
want to surrender collateral and reduce or eliminate debt?______________________________
Loans for Jewelry, Gifts & Household Goods
Secured Creditor 1 (Describe items purchased)_____________________________________
Finance/loan company:_____________________________ Acct #:__________________________
Address:_________________________________________ Monthly payment: $______________
City:_________________ ST: ______ Zip:___________ Total loan payoff: $_______________
In whose name:___________________ Co-signers:_____________________________________
When did you take out loan:______________________ Do you still have items:______________
If not, who has them or what happened to items?_________________________________________
Do you want to surrender collateral and reduce or eliminate debt?__________________________
Secured Creditor 2 (Describe items purchased)_____________________________________
Finance/loan company:_____________________________ Acct #:__________________________
Address:_________________________________________ Monthly payment: $______________
City:_________________ ST: ______ Zip:___________ Total loan payoff: $_______________
In whose name:___________________ Co-signers:_____________________________________
When did you take out loan:______________________ Do you still have items:______________
If not, who has them or what happened to items?_________________________________________
Do you want to surrender collateral and reduce or eliminate debt?__________________________
Secured Creditor 3 (Describe items purchased)_____________________________________
Finance/loan company:_____________________________ Acct #:__________________________
Address:_________________________________________ Monthly payment: $______________
City:_________________ ST: ______ Zip:___________ Total loan payoff: $_______________
In whose name:__________ Co-signers:_______________ When did you take out loan:__________
Do you still have items:________ If not, what happened to items?____________________
Do you want to surrender collateral and reduce or eliminate debt?__________________________
Student Loans .(if needed, list on separate sheet of paper & attach)
Student Loan Creditor 1
Student loan lender:_____________________________ Acct #:__________________________
Address:_________________________________________ Monthly payment: $______________
City:_________________ ST: ______ Zip:___________ Total loan payoff: $_______________
In whose name:___________________ Co-signers:_____________________________________
When did you take out loan:___________ Name of school attended:______________________
Is loan in default?___________________ Is loan in deferment?:_________________________
Student Loan Creditor 2
Student loan lender:_____________________________ Acct #:__________________________
Address:_________________________________________ Monthly payment: $______________
City:_________________ ST: ______ Zip:___________ Total loan payoff: $_______________
In whose name:___________________ Co-signers:_____________________________________
When did you take out loan:___________ Name of school attended:______________________
Is loan in default?___________________ Is loan in deferment?:_________________________
Health Club/Spa Membership .(if needed, list on separate sheet of paper & attach)
Health Club Finance Company:______________________________________________
Address:_________________________________________ Monthly payment: $______________
City:_________________ ST: ______ Zip:___________ Total loan payoff: $_______________
In whose name:___________________ Co-signers:_____________________________________
Do you still use facility:___________ Did you sign a contract:_________________________
Do you want to continue to use this facility/club:_____________________________________
Credit Cards .(if needed, list on separate sheet of paper & attach)
Credit Card Lender 1:____________________________ Acct #:__________________________
Correspondence Address:____________________________________ Monthly pymt: $______________
City:_________________ ST: ______ Zip:___________ Total loan payoff: $_______________
In whose name:___________________ Co-signers:_____________________________________
When is the last time you used this card?_____________________ What did you buy:___________
During the last 6 months, have you used this card more frequently than before__________________
Collection agency name, address, acct #:________________________________________________
________________________________________________________________________________
Credit Card Lender 2:____________________________ Acct #:__________________________
Correspondence Address:____________________________________ Monthly pymt: $____________
City:_________________ ST: ______ Zip:___________ Total loan payoff: $_______________
In whose name:___________________ Co-signers:_____________________________________
When is the last time you used this card?_____________________ What did you buy:___________
During the last 6 months, have you used this card more frequently than before__________________
Collection agency name, address, acct #:________________________________________________
________________________________________________________________________________
Credit Card Lender 3:____________________________ Acct #:__________________________
Correspondence Address:____________________________________ Monthly pymt: $____________
City:_________________ ST: ______ Zip:___________ Total loan payoff: $_______________
In whose name:___________________ Co-signers:_____________________________________
When is the last time you used this card?_____________________ What did you buy:___________
During the last 6 months, have you used this card more frequently than before__________________
Collection agency name, address, acct #:________________________________________________
Credit Card Lender 4:____________________________ Acct #:__________________________
Address:_________________________________________ Monthly payment: $______________
City:_________________ ST: ______ Zip:___________ Total loan payoff: $_______________
In whose name:___________________ Co-signers:_____________________________________
When is the last time you used this card?_____________________ What did you buy:___________
During the last 6 months, have you used this card more frequently than before__________________
Collection agency name, address, acct #:________________________________________________
Credit Card Lender 5:____________________________ Acct #:__________________________
Address:_________________________________________ Monthly payment: $______________
City:_________________ ST: ______ Zip:___________ Total loan payoff: $_______________
In whose name:___________________ Co-signers:_____________________________________
When is the last time you used this card?_____________________ What did you buy:___________
During the last 6 months, have you used this card more frequently than before__________________
Collection agency name, address, acct #:________________________________________________
Credit Card Lender 6:____________________________ Acct #:__________________________
Address:_________________________________________ Monthly payment: $______________
City:_________________ ST: ______ Zip:___________ Total loan payoff: $_______________
In whose name:___________________ Co-signers:_____________________________________
When is the last time you used this card?_____________________ What did you buy:___________
During the last 6 months, have you used this card more frequently than before__________________
Collection agency name, address, acct #:________________________________________________
Credit Card Lender 7:____________________________ Acct #:__________________________
Address:_________________________________________ Monthly payment: $______________
City:_________________ ST: ______ Zip:___________ Total loan payoff: $_______________
In whose name:___________________ Co-signers:_____________________________________
When is the last time you used this card?_____________________ What did you buy:___________
During the last 6 months, have you used this card more frequently than before__________________
Collection agency name, address, acct #:________________________________________________
________________________________________________________________________________
Credit Card Lender 8:____________________________ Acct #:__________________________
Address:_________________________________________ Monthly payment: $______________
City:_________________ ST: ______ Zip:___________ Total loan payoff: $_______________
In whose name:___________________ Co-signers:_____________________________________
When is the last time you used this card?_____________________ What did you buy:___________
During the last 6 months, have you used this card more frequently than before__________________
Collection agency name, address, acct #:________________________________________________
________________________________________________________________________________
Credit Card Lender 9:____________________________ Acct #:__________________________
Address:_________________________________________ Monthly payment: $______________
City:_________________ ST: ______ Zip:___________ Total loan payoff: $_______________
In whose name:___________________ Co-signers:_____________________________________
When is the last time you used this card?_____________________ What did you buy:___________
During the last 6 months, have you used this card more frequently than before__________________
Collection agency name, address, acct #:________________________________________________
Medical Bills .(if needed, list on separate sheet of paper & attach)
Medical provider 1:__________________________________ Acct. #:____________________
Address:_________________________________________ Monthly payment:_____________
City:_____________________ ST: _________ Zip:__________ Total balance due:__________
In whose name:_____________________ Co-signers:___________________________________
Do you still use this health care provider?______________ When last used:__________________
Collection agency name, address, acct #_______________________________________________
_______________________________________________________________________________
Medical provider 2:__________________________________ Acct. #:____________________
Address:_________________________________________ Monthly payment:_____________
City:_____________________ ST: _________ Zip:__________ Total balance due:__________
In whose name:_____________________ Co-signers:___________________________________
Do you still use this health care provider?______________ When last used:__________________
Collection agency name, address, acct #_______________________________________________
Medical provider 3:__________________________________ Acct. #:____________________
Address:_________________________________________ Monthly payment:_____________
City:_____________________ ST: _________ Zip:__________ Total balance due:__________
In whose name:_____________________ Co-signers:___________________________________
Do you still use this health care provider?______________ When last used:__________________
Collection agency name, address, acct #_______________________________________________
Medical provider 4:__________________________________ Acct. #:____________________
Address:_________________________________________ Monthly payment:_____________
City:_____________________ ST: _________ Zip:__________ Total balance due:__________
In whose name:_____________________ Co-signers:___________________________________
Do you still use this health care provider?______________ When last used:__________________
Collection agency name, address, acct #_______________________________________________
Medical provider 5:__________________________________ Acct. #:____________________
Address:_________________________________________ Monthly payment:_____________
City:_____________________ ST: _________ Zip:__________ Total balance due:__________
In whose name:_____________________ Co-signers:___________________________________
Do you still use this health care provider?______________ When last used:__________________
Collection agency name, address, acct #_______________________________________________
Medical provider 6:__________________________________ Acct. #:____________________
Address:_________________________________________ Monthly payment:_____________
City:_____________________ ST: _________ Zip:__________ Total balance due:__________
In whose name:_____________________ Co-signers:___________________________________
Do you still use this health care provider?______________ When last used:__________________
Collection agency name, address, acct #_______________________________________________
Other Creditors/Extra space .(if needed, list on separate sheet of paper & attach)
Pension or 401(k) Loans
Type of investment ____________________________ Acct #:__________________________
Address:_________________________________________ Monthly payment: $______________
City:_________________ ST: ______ Zip:___________ Total loan payoff: $_______________
In whose name:___________________ Co-signers:_____________________________________
When did you take loan out?_________________ How long will loan last?_________________
Creditor/Lender :____________________________ Acct #:__________________________
Address:_________________________________________ Monthly payment: $______________
City:_________________ ST: ______ Zip:___________ Total loan payoff: $_______________
In whose name:___________________ Co-signers:_____________________________________
What type of debt is this?_________________________________ What did you buy:___________
Collection agency name, address, acct #:________________________________________________
Creditor/Lender :____________________________ Acct #:__________________________
Address:_________________________________________ Monthly payment: $______________
City:_________________ ST: ______ Zip:___________ Total loan payoff: $_______________
In whose name:___________________ Co-signers:_____________________________________
What type of debt is this?_________________________________ What did you buy:___________
Collection agency name, address, acct #:________________________________________________
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Please print the questionnaire below, fill it out and return for
processing. Click on 'Letter' for additional bankruptcy information
that will aid in the bankruptcy process. Thank you!
processing. Click on 'Letter' for additional bankruptcy information
that will aid in the bankruptcy process. Thank you!
| Our goal is to help you get out of debt. |