Bankruptcy Evaluation Form

Your Name (required)

Address (required)

Phone (required)

Your Email (required)

Best time to contact you? (required)

What type of bills do you have?
(Check all that apply)
Credit CardsMedical BillsJudgmentsStudent LoansTax DebtsGovernment FinesPersonal 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 - $50,000Over $50,000

Approximate value of home:

Approximate balance on mortgage:

Monthly mortgage payment:

Are you up to date on your mortgage payments?
YesNo

Are there any other mortgages on this property?
YesNo

Vehicle 1

Year/Make/Model:

Approximate Value:

Approximate Balance:

Monthly Payment:

Are your payments up to date?
YesNo

Vehicle 2
Year/Make/Model:

Approximate Value:

Approximate Balance:

Monthly Payment:

Are your payments up to date?
YesNo

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

You

Are you employed?
YesNo

How often do you get paid?
every weekevery 2 weekstwice a monthmonthly

Net Pay:
(after taxes, medical adn other deductions)

What other types of income do you have?
(Check all that apply)
DisabilitySocial SecurityPensionRental PropertyPart-time JobChild SupportUnemploymentWorker's Compensation

Spouse (optional)
How often do you get paid?
every weekevery 2 weekstwice a monthmonthly

Net Pay:
(after taxes, medical and other deductions)