| Full Name
|
|
| Address
|
|
| Phone
|
|
| Email Address
|
|
| Best time to contact you?
|
|
What type of bills do you have?
(Check all that apply)
|
Credit Cards
Medical Bills
Judgments
Student Loans
Tax Debts
Government Fines
Personal Loans
|
| Number of bills
|
|
| Amount Owed:
|
Under $5,000
$5,000 - $10,000
$10,000 - $15,000
$15,000 - $20,000
$20,000 - $30,000
$30,000 - $40,000
$40,000 - $50,000
Over $50,000
|
| Approximate value of home:
|
$
|
| Approximate balance on mortgage:
|
$
|
| Monthly mortgage payment:
|
$
|
| Are you up to date on your mortage payments?
|
Yes
No
|
| Are there any other mortgages on this property?
|
Yes
No
|
Vehicle 1
Year/Make/Model:
|
|
| Approximate Value:
|
$
|
| Approximate Balance:
|
$
|
| Monthly Payment:
|
$
|
| Are your payments up to date?
|
Yes
No
|
Vehicle 2
Year/Make/Model:
|
|
| Approximate Value:
|
$
|
| Approximate Balance:
|
$
|
| Monthly Payment:
|
$
|
| Are your payments up to date?
|
Yes
No
|
You
How often do you get paid?
|
every week
every 2 weeks
twice a month
monthly
|
Net Pay:
(after taxes, medical adn other deductions)
|
$
|
What other types of income do you have?
(Check all that apply)
|
Disability
Social Security
Pension
Rental Property
Part-time Job
Child Support
Unemployment
Worker's Compensation
|
Spouse(optional)
How often do you get paid?
|
every week
every 2 weeks
twice a month
monthly
|
Net Pay:
(after taxes, medical adn other deductions)
|
$
|
| |
|
