Name:

Best way to contact you (home or cell):

Best time to contact you:

City where you live:

Have you ever filed bankruptcy before?

If yes, what chapter?

When?

Are you married?

Do you plan to file bankruptcy with your spouse?

Do you own any real estate?

If yes, what is its fair market value (comparative market analysis, tax assessed value, or appraisal)?

What is the total payoff on your mortgage(s)?

Are you up to date on your mortgage payments?

What is your gross annual income?

What is the gross annual income of your spouse (whether you are filing individually or jointly)?

Approximately how much income did you earn in the last six months?

Approximately how much income did your spouse earn in the last six months?

Are you up to date on filing your tax returns?

Do you own any vehicles?

If yes, how many?

For each vehicle, please provide the following information:

• Year, make, and model

• Miles

• What is the total payoff of each vehicle’s loan?

What is the approximate total amount of all other debts you have (credit cards, personal loans, medical bills, etc)?