Filing Form

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Bankruptcy online Questionnaire

Print this form and bring it with you.  
If you do not have some of the information, we will help you fill it in.

1) INFORMATION:

First Name:
Last Name:
Address:
City:
State:
Zip Code:
E-Mail:
Phone:

2) NATURE OF FINANCIAL DIFFICULTY:

3) TYPE OF LEGAL SERVICES SOUGHT:

Bankruptcy Case:
Chapter 7
Chapter 13
Chapter 11
Negotiation With Creditor(s)
Short Sale to Reduce Mortgage
I.R.S. Representation
Other Specify:

4) DEBTS:

Type of Debt Amount # of
Creditors		 Status
Credit Cards
Medical Bills
Car Loan/Car Lease
Mortgage
Taxes
Other:

5) ASSETS:

Type of Asset Description Fair
Market
Value		 Ownership
and/or Liens
House (Appraisal)
Car (Name, Model, Mileage)
Bank Account
Liquidation Value of Furniture
Investments
Retirement Account
Other Property Having Value

6) INCOME / EXPENSES MONTHLY:

Average Monthly Net Income
Average Monthly Expenses

7) MORE INFORMATION REGARDING TYPE OF DEBT:

A) Mortgage Arrears:

Amount

# Month

Monthly payment
B) Credit Cards:
Any Joint Holder?
Last Time Used
Able to Pay at Time of Use?
Any Cash Advances?
Any Luxury Items?
C) Taxes:

Yes

 No
Is it an Income Tax?
Is Tax Over Three Years Old?
Has Taxing Authority Assessed Within 240 Days?
Any Liens?

8) How Did You Hear About Us?:

Attorney Locate
Attorney Find
Find a Site
Other, Specify