Full Name

Address:

Phone #:

Your Email

Best time to contact you?

What types 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 mortage payments?
 yes no

Are there any other mortgages on this property?
 yes no

Vehicle 1

Year/Make/Model

Approximate Value

Approximate Balance

Are your payments up to date?

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

Are you employed?
 yes no

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

What is your 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(optional)

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

What is your net pay?(after taxes, medical and other deductions)