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 mortgage 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

Enter any other property of significant value
(For example, if you own a boat list it here)

You
Are you employed?
 Yes No

How often do you get paid?
 every week every 2 weeks twice a month monthly

Net Pay
(After taxes, medical, and 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
How often do you get paid?
 every week every 2 weeks twice a month monthly

Net Pay
(After taxes, medical, and other deductions)

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