1. Have you filed for bankruptcy in the last 8 years? *

Year Filed:

Chapter filed:

2. Household size (including dependents): *

3. Marital Status: *

Married

Single

Divorced

Widowed

If you are married, are you filing jointly?

Yes

4. Monthly household income (before taxes): *

Do you have disposable Income*?

*The amount of money remaining after deducting taxes and other mandatory expenses

5. Do you own your primary residence? *

Primary Residence Address:

Residence Value ($):

Mortgage Balance ($)

Residence Retain or Surrender?

6. How much unsecured debt do you owe? Include all credit cards, unsecured loans, medical bills, bank overdrafts, repossessions, etc. *

Are you behind on Mortgage or Car?

7. Do you owe on any secured items? *

Secured Debt 1: Item Description (Year/Make/Model):

Secured Debt 1: Item Type

Secured Debt 1: Value ($)

Secured Debt 1: Owed ($)

Secured Debt 1: Retain or Surrender

Secured Debt 1: Do you have more Secured Debt?

Secured Debt 2: Item Description

Secured Debt 2: Item Type

Secured Debt 2: Value ($)

Secured Debt 2: Owed ($)

Secured Debt 2: Retain or Surrender

Secured Debt 2: Do you have more Secured Debt?

Secured Debt 3: Item Description

Secured Debt 3: Item Type

Secured Debt 3: Value ($)

Secured Debt 3: Owed ($)

Secured Debt 3: Retain or Surrender

Secured Debt 3: Do you have more secured debt?

Secured Debt 4: Item Description

Secured Debt 4: Item Type

Secured Debt 4: Value ($)

Secured Debt 4: Owed ($)

Secured Debt 4: Retain or Surrender

Secured Debt 4: Do you have more secured debt?

Secured Debt 5: Item Description

Secured Debt 5: Item Type

Secured Debt 5: Value ($)

Secured Debt 5: Owed ($)

Secured Debt 5: Retain or Surrender

8. Have you filed all required tax returns? *

Do you owe tax debt?

Tax Amount Owed ($):

9. Do you pay or receive child support? *

Monthly Amount Paid ($):

Are payments current?

How much unpaid child support is still owed?

Monthly Amount Received ($):

Is there any unpaid child support owed to you?

Amount Owed to You ($):

11. What is your goal? *

To keep home/car

To have fast discharge, no payment plan

To protect nonexempt equity or repay over time

Not sure, exploring options

12. Anything else we should know?

Full Name *

Email *

Phone *

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