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Basic Information
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First name*
Last name*
Phone number*
Email:
Address
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Financial Information
#1 - House
Do you own a home?
Check box if "Yes"
How much do you owe on the home?
What is your home's value?
How did you value your home?
recent appraisal
assessed value
best guess
other
Are you current on your mortgage payment?
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#2 - Automobiles
(Cars, trucks, RVs, motorcycles, etc)
Year, make, and model
Monthly payment
Current on payments?
Total Balance
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Auto #1
Auto #2
Auto #3
Auto #4
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No
Yes
No
Yes
No
#3 - Other Bills
If not applicable, write "NA". Otherwise, fill out as much as possible.
Monthly payment
Total Balance
Mortgage or Rent
Credit cards
Student loans
Past taxes
Medical bills
Alimony/Child Support
Daycare
Other (describe)
#4 - Income
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Your net monthly income:*
(after deductions)
Your spouse's net monthly income:
Source of
your
monthly income
(check all that apply)
Full time employment
Part time employment
Pension
Unemployment
Social Security
Disability
Worker's Comp
Child Support
Other (explain)
#5 - How did you hear about The Law Office of Jeffrey Totten?
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#6 - When would you like to meet?
(general time of the day and day of the week)
Free Online Bankruptcy Evaluation