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Bankruptcy Evaluation Form
Full Name
*
Email (we will never spam you)
*
City
Telephone: At least one personal telephone number is required.*
Home
*
Cell
Office
Please check all that apply to you:
Are you married?
Yes
No
Home Mortgage
Any arrears?
Yes
No
How many months behind?
Car Payment 1
Any past due payments?
Yes
No
Year and type of car:
Car payment 2
Any past due payments?
Yes
No
Year and type of car:
Student Loans (most student loans cannot be eliminated by bankruptcy)
IRS back taxes - what years?
Credit Card Debt: Approximate total $ amount
Medical Bills
Lawsuits or Judgements
Real estate back taxes
Child Support: Monthly $
Other debts not included above.
Which of the following assets do you own?
Please click on the correct answer and fill in all the blanks that apply to your case.
Home: Do you intend to keep and pay for your home?
Yes
No
Amount owed on mortgage $
Value of home $
Car #1: Do you intend to keep and pay for you vehicle?
Yes
No
Car #2: Do you intend to keep and pay for your vehicle?
Yes
No
House or real estate other than home
Stocks and bonds: Approximate value $
Lawsuit or potential lawsuit against a company or person
Income. Please click on the correct answer and fill in all applicable blanks.
I am currently employed
Net monthly pay $
I have a spouse who is currently employed.
Net monthly pay $
Social Security or retirement income
Monthly amount $
I or my spouse receive Child Support
Monthly amount $
Other income
Other income description
I own a business
Type of business:
Incorporated
Yes
No
DBA
Yes
No
Partnership
Yes
No