MOTIVATION

What motivated you to seek information about bankruptcy? Check all that apply.

Stop Home Foreclosure

Stop Wage Garnishment

Stop Repossession of Personal Property

Stop Creditor Harassment

Eliminate Credit Card Debt

Consolidate Student Loans

Other

Have you filed bankruptcy before? Yes No

If so what chapter? Chapter 7 Chapter 13

When?

BILLS

What bills do you have? Check all that apply.

Credit Cards

Personal Loans

Medical Bills

Student Loans

Tax Debt

Judgment

Government Fines

Other

ASSETS
Do you own real estate? Yes No

If yes, how many?

Are you current on your payments? Yes No

If no how many months are you behind?

Approximately how much behind?

INCOME
Are you employed? Yes No

Are you self employeed? Yes No

Select all other income you have.
Disability

Social Security

Pension / Retirement

Rental Income

Child Support

Workers Compensation

Unemployment

Other

CONTACT INFORMATION

First Name

Last Name

Email

Address

City

State

Zipcode

County

Preferred Phone

Is there any additional information you would like to share?